Palliative care Head Nurse Vasiliki (Bessy) Bitzas on the value of people’s stories, the crucial role of nurses, and the importance of continuity of care
“For me it is very important to be able to run smaller but very clinically focused research projects that actually improve the quality of care to our patients here.”
By Devon Phillips. Vasiliki (Bessy) Bitzas says that so much of her career has come about by chance. But this is hard to believe, given her accomplishments both as a clinician and as an academic. Having graduated with her doctorate from McGill in June 2014, Bessy embraces her roles as a head nurse and as a researcher, and expresses a keen interest in implementing research findings to directly improve the care of patients in palliative care. I met with Bessy in her office on the palliative care unit of the Jewish General Hospital in Montréal, Québec.
Q: What led you to palliative care?
A: The real answer? It was totally by accident! When I was doing my Master’sdegree in the late 90’s, I had received a research grant and part of that funding was to work in a summer camp, Camp Positive, for people with AIDS. I was sort of plopped into that as a student researcher and developed a pre-and post-test evaluation to see if the camp was effective in improving the quality of life of the camp participants. That was my first real exposure to dying patients. My Master’s thesis studied the infant feeding choices of primiparousadolescent mothers, quite unrelated to palliative care. While I was still in school, I started working a few hours a week here at the JGH on Four Main as a student nurse doing basic care. I was bathing, feeding, positioning patients. At the time Four Main was technically a family medicine ward I think, so we saw all sorts of patients. This was invaluable experience for me particularly since I was enrolled in the Direct Entry Masters Nursing program at McGill, which is a three-year graduate program for individuals who are not registered nurses. It’s a wonderful and intense program, the only one of its kind in Canada, where people from varied backgrounds, including the arts, sciences, and humanities, graduate with an advanced degree and all of the qualifications required to write the licensing exam to work as a registered nurse. When I graduated, I was hired as a staff nurse on the same unit. Then, about a year later, the head nurse on the Neurology ward went on maternity leave and I decided, pretty much at the last minute, to apply. I was happy where I was, but I saw this as an opportunity to try something new, temporarily, given that it was a maternity leave replacement. I was pretty junior, so I didn’t actually expect that I would get the job, but I did and so I did that for about a year. Then Dr. Lapointe came on as Chief of Palliative Care at the JGH and the Division of Palliative Care was officially established in 2000. Soon after, the position of Head Nurse of Palliative Care became available and I applied for it. Ultimately, my stint in neurology was helpful as I had some administrative experience under my belt, and I found that I liked it. So it all seems as though it happened quite by chance. The right circumstances at the right time. Although I initially did not seek out work in palliative care, I enjoyed the type of care we provided. I felt, and I still do, that it was very gratifying work, and that it was the right fit for me. And fit is important. You know, I could not be a nurse in the ICU or emergency, that’s not where my strengths lie, it is not in keeping with my personality. Whereas here in palliative care, I feel at home.
Part of it is that I love getting to know people, establishing relationships. In palliative care, hearing peoples’ stories is valued and it ultimately helps you take care of the patient and the family, so it’s valued and it’s valuable. Over the past number of years working here, I still remember some of the patients and families I have met. They are individuals who are permanent members of my memory - I remember the way they looked, what they said, what we shared. I remember what it was like to care for them. It’s a very enriching experience working here.
Q: It seems like nurses in palliative care are in a very demanding situation- someone comes in with a short period of their life left and the nurses get close to that person and the family. Is this true?
A: It’s a very intense period of time and even the smallest interaction with somebody has meaning. For this family, for this patient, you are THE nurse who was there when their loved one died, so the impact that we have on the patients and families is tremendous. Part of my job is ensuring that the nurses working directly with the patients remember this, and recognize how true it is. And I can do my best to describe what the nurses in palliative care live every day, but no words could do justice to the magnitude of work, the emotional investment, the commitment which drives them every day. It is really remarkable.
Q: Tell me about your role as head nurse.
A: I think, to a certain extent, you can make the head nurse role what you want. The administrative responsibilities are clearly not negotiable and make up a good portion of the job. But, I’m also involved in education and research, which are not head nurse requirementsper se, but I believe that they make the unit run more smoothly and they certainly make my job more satisfying. But as a head nurse you also have the opportunity to be clinically invested. In my opinion, this is actually not an option. I have always believed that you cannot manage that which you don’t understand. It would be impossible and unjust to try to manage a department, and the staff who work there, without actually knowing what the realities are, what the challenges are, what the strengths are. I take the time to know the patients on the unit, to meet with the families, to discuss their care with the staff. And by the same token I take the time to truly get to know my staff. I have an open door policy, and when we were redesigning the unit I insisted that my office be within the nursing station, so that I am physically close to the nurses and other team members if they need me. No matter what I am doing, I always make the time to speak to my staff about work issues, or personal issues if I am asked, and if I can be of help. My job is to take care of my staff in the best way I can so that they can then take care of our patients.
So that is my job in a nutshell, and I must say that my job is made much easier because I have perhaps the most wonderful team of nurses working with me. They are truly remarkable, each and every one of them. I hope that there is an opportunity for you to interview one of the staff nurses as well…theirs would likely be a much more inspiring read.
On the Palliative Care Unit we follow a model of primary nursing so the nurse who admits a patient onto the unit becomes that patient’s and family’s primary nurse. This means that everytime she works, that nurse is assigned to that patient. This helps to establish a collaborative relationship which is built on trust, mutual goal setting and deep understanding. In many ways the primary nurse becomes the anchor for this patient and family and just as physicians have “their” patients, nurses have “their” patients too. This model promotes continuity of care and fosters nurse-patient engagement.
Q: You sound very proud of the palliative care unit.
A: I am very proud of the unit! And I recognize that the unit’s success did not just happen, that there is a lot of work, sometimes invisible work, that goes into it. It’s important that as nursing leaders we acknowledge that we play a crucial role in maintaining good team spirit, and in instilling pride in the nurses; they do such a great job. And pride comes from being able to evaluate their own work, to question it, to improve upon it, to receive positive feedback and constructive criticism. To recognize that we are all human, we make mistakes, we have good days and bad, but that no one does this work alone, and that there is an entire team working together. One of the things that I look at when I try to gauge the pulse of the unit at any given time is looking at my staff retention. The staff turnover is really low here, and that’s because people are happy. It may sound simplistic, but a happy and supported staff is critical. If the nurses are not happy, it they don’t feel supported, then they are unable to take good care of their patients, and taking care of patients is the reason why we are here.
Q: Did Dr. Lapointe’s arrival instill a particular philosophy in the palliative care unit?
A: When he came, we officially became a division and that gave us credibility and recognition. As a division, we have a focused and clear mandate, to improve the quality of life of patients with life-threatening illness, and their families, and to do so by preventing and relieving both physical and psychological symptoms. And of course we suddenly had beds which were assigned to palliative care, which was a big change. Bernard came with a lot of experience, connections, and knowledge. I remember that when he started, he met individually with every single nurse, including me, to talk about how their work was going, what their vision was for the unit, what they wanted to change. I thought that this showed a great commitment on his part and was an indication that he was a true proponent of team work. He was interested in working with an interdisciplinary team and this was the beginning of our physician-nurse co-management of the division. He has been a wonderful partner and we have learned a lot from each other.
Q: So the division of palliative care was established and you were head nurse. What motivated you to pursue a doctorate?
A: I was several years into my career and quite content, still very motivated and enthusiastic, but I found myself wondering what more there was to do. I have always loved learning, loved school. University for me was a privilege which I never took lightly. At the time, my nursing director was very like-minded. She recognized the value of having doctorally-prepared nurses working in the institution and encouraged me to apply to the PhD program at McGill. It was not an easy decision as my children were quite young, 7 and 4 years old at the time, but my husband is incredibly supportive and his reaction when I brought this up was, “we will figure it all out…just do it”. So, I did… a bit naively I’ll admit as I was not really aware of the magnitude of what I had just signed up for.
Q: So you were in deep!
A: Yes! The program at McGill is quite intense and for the first year I was working full time while being registered as a full time student. Time management became quite important and there was a lot of juggling of responsibilities. After my second year I was able to secure funding and took a partial study leave of absence from work. I began the program in the fall of 2008 and defended my thesis on June 5, 2014. When I look back at that time I think, “How the heck did I do that?” I remember each evening my daughters would ask who had more homework that night, them or me.
Q: What was the focus of your coursework?
A: There are a required set of courses which the School of Nursing obliges all doctoral students to take, and I supplemented those with courses which I felt would contribute to my learning and future research. So, I took an advanced statistics course, a course on psychosocial oncology, one on qualitative research methods and one on palliative care. This was in addition to the required courses…so it was quite busy. Dr. Robin Cohen, the Director of Palliative Care Research at McGill was my thesis supervisor, which was fortunate because I already knew her and of course because she is such an established palliative care researcher. She recognized my experience and was really wonderful in allowing me to direct my research in collaboration with her. I decided to focus on the experience of hospitalized, dying patients waiting to transfer to a palliative care unit. I conducted an interpretive phenomenology which is a qualitative research methodology that’s based in Heideggerian philosophy. I actually also audited a philosophy course on Heidegger in order to fully immerse myself in interpretive phenomenology. In very simple terms, interpretive phenomenology is about interpreting people’s accounts of what they experienced and then presenting these interpretations as knowledge which is created. So, I had conversations with imminently dying people on the acute care wards once they knew they were waiting to be transferred to the palliative care unit, documented these encounters and analyzed the transcripts through an interpretive lens.
Q: That must have been an amazing study.
A: It was great. Findings aside, what was really interesting is that there are opportunities to do research with people, even when they are very close to death. The idea that they are not going to want to engage in research, or that they’ll be too tired or too weak, is not necessarily true. I had participants who died a few days after I met with them. They were really quite sick and yet they were willing to share their stories with me, to spend precious time with me. I remember one man, he was coughing a lot, and I kept saying, “You know, we can stop,” but he wanted to finish and at the end he said, “Thank you so much for seeing me because it gave me an opportunity to think about things I would not have thought about.” He died three days later. Working with him was such an enriching experience.
Q: So you did your Master’sdegree here at McGill and your doctorate at McGill as well. How have these pursuits contributed to your career in palliative care?
A: Well, I now have a joint position as an Associate Professor at the Ingram School of Nursing at McGill and I continue working in my current position as palliative care head nurse. The difference is that I can now use what I have learned through my doctoral training program including how to conduct research and how to apply for funding, and connect with other researchers. Within the context of my current job, I am collaborating on a recently funded multi-site project exploring the relationship between genetic testing and health care professionals in palliative care and am also working on developing a few smaller studies building upon my doctoral work. I am also the Chair of the Research Ethics Committee at the JGH, which is neat since it is pretty uncommon to have a nurse act as chair on this committee.
Q: Can you give me an idea of your areas of interest. Where are you headed academically, and in your research?
A: Nursing research in palliative care is rich with opportunities and sometimes I need to remind myself that I cannot study everything! I continue to be very drawn to research which highlights the individual experience. I have studied patients’ experience with transitioning from acute care to palliative care and now I would like to look at this through the lens of the families. I am also quite fascinated by the study of space and place, and how those elements in patients’ environments can influence their end-of-life experience. One of the main problems with research is that it can often occur in a silo, separated from the reality of the clinical world. In my view, if excellent research and significant research findings do not grow from clinical, real-world needs, nor get transferred back to somehow influence the care of the patient, it makes the whole endeavor questionable. My goal has never been to chase after huge grants, thankfully, because that is really hard work! I feel that there is a lot of valuable research which can be done on a smaller scale. For me, it is much more important to be able to run smaller but very clinically focused research projects that actually improve the quality of care to our patients here. I think that because of my clinical and administrative experience, and because I am so close to the ground, I can focus on what the needs actually are, at least as I recognize them. Research does not have to be huge; it certainly can be and there is significant value in that, but small, focused projects also have their place in the research world.
Q: It sounds really useful to be able to work with your clinical and research streams synergistically.
A: Yes, I feel lucky because for many researchers part of their dilemma is knowledge translation: how do we bring research to the clinical world and how do we get clinicians to buy into our research and help us recruit, be engaged, be committed? I have a foot in both of those worlds every day. I’m very fortunate.
Q: Have you any opportunity to apply any of the findings from your research to your clinical practice?
A: Yes. One of the findings in my doctoral work was that patients felt much more secure in the transition to palliative care when they actually knew more about where they were being transferred to, what the philosophy was, what the care was like, even what the physical environment looked like. While the supportive care team talks to patients and they do a great job, the nurses on the acute care wards are the ones who are actually there from the moment the patient is put on the waiting list for palliative care, to the time they get transferred. So I am currently working on ways to educate the nurses on these referring units about what they should be telling patients and their families, what information is most useful and supportive for them.