By Richard H. Savel, MD, and Cindy L. Munro, RN, PhD, ANP
THE ESSENCE OF NURSING
Critical Care Exposition (NTI). The energy and excite-
ment in the air were palpable. Many of us anticipate
an exciting time at NTI, but in contrast to other pro-
fessional meetings, we rarely expect to be moved to
tears by public demonstrations of what it is to be an
intensive care unit (ICU) clinician, and to be reminded
in a glorious fashion how difficult and important all
of our jobs are.
This was particularly true of a brief but powerful
presentation by nurse Jasper Tolarba. At the end of
his narrative, many in the audience of more than
5000 were reduced to tears by his ability to touch
us all; he reminded us about the importance not
only of dignity for the patient but, when necessary,
dignity for the ICU staff. His talk also emphasized
the power of remaining calm, cool, collected—and
kind! His story is presented (with his permission)
in its entirety below:
arlier this year, we had the distinct honor of
attending the American Association of Critical-
Care Nurses’ National Teaching Institute and
The moment I had been dreading hap-
pened today. As soon as I entered my patient’s
room, she stared at me and asked, “Who are
you?” I answered, “My name is Jasper and I
will be your nurse for tonight.” Before I could
finish, she asked, “Where are you from?” I
told her that I came from the Philippines. Her
look turned to disgust and she said, “Oh, Jesus!
I’ve heard a lot about you people. You come
here in troops, and you work for almost
I wanted the ground to open up and
swallow me whole. I felt the blood rushing
to my face with intense humiliation. In my 4
months of bedside nursing in the United States,
I had not been put in such a difficult situa-
tion. My patients were usually very friendly
and pleasant. But there I was, face-to-face
with an 80-year-old lady catching me unpre-
pared. I gathered my wits and replied, “You
must be upset. You know, I’m just here to
take care of you.” I knew this would not pla-
cate her. “We have a lot of you here already,”
she said. “Why do you come here? Because
you cannot work in your own country?” It
was too much of an insult for me to take. At
first, I thought of walking out of the room to
save myself from more humiliation. But what
would that make me?
Instead, I found myself approaching my
patient. Touching her on the shoulder, I said,
“With all due respect, ma’am, what you just
said is rather degrading. Do you really want
to know why we are here? It’s because you
don’t have enough nurses to take care of the
ailing population in this country. That is why
they invite us to work as nurses here, to fill
your great shortage. Otherwise, there might
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be nobody to take care of you one day.” She
was speechless. I straightened myself and
helped her to turn over. I did my assessment,
perineal care, and put a new Depends pad on
her. I then started giving her a back massage
explaining to her that it would help improve
She finally spoke. “That feels good,” she
said. “I wish the other nurse did the same
thing for me.”
I began to wonder if this was the same
patient who belittled me just minutes ago.
When I walked out of her room, my heart
was light. The magic of tenderness, love, and
care had transcended hatred and prejudice.
This is what I like about nursing. It knows no
color, sex, age, social status, nor race.
My philosophy in life is that any human
being, however unpleasant, yields to the hon-
est, caring hands of another. I believe this is
the essence of nursing—to heal not only the
ailing physical body, but also to mend bruised
feelings and self-esteem. And on that particu-
lar night, my self-esteem was healed, too.
Complex Multicultural Issues
Those of us who practice in cities or towns
with diverse populations must be highly sensitized
to how complex multicultural and cross-cultural
issues can be in the hospital setting. Particularly in
the ICU, patients and their families are often highly
stressed and may sometimes say things they either
do not really mean or would not normally say.
Patients and families are often fighting for atten-
tion from an overworked and understaffed multi-
disciplinary team, and may become frustrated if
they feel their needs are not being met with appro-
priate alacrity. Although much has been written
about providing care with dignity for patients (as
there should be!),1-3it is much more difficult to
find literature that focuses on ensuring the clinical
staff is treated with dignity. This is wrong.
Of course, as professionals we are trained not
to respond emotionally when patients or their fam-
ily members say or do things that we as the treating
clinicians may consider to be inappropriate or offen-
sive. Perhaps they are just afraid or stressed and tak-
ing it out on us, the professionals who are trying our
hardest to help them or their loved one. But just as
importantly—in this era of nursing shortages and
terrible burnout—it does not mean that we must suf-
fer silently when what is happening clearly verges on
what can only be termed “abuse.”4-8
As nurse Tolarba elegantly reminds us, it not
only acceptable, but of the highest imperative that
we recognize when our patients are hurt, in pain,
stressed, upset, or delirious and provide them care
and comfort to the best of our abilities. In addition,
we also must stand up for ourselves when we feel
our patients are “taking advantage” of us and not
providing us the dignity and mutual respect we all
deserve as part of the multidisciplinary team.
There are multiple important reasons why the
vignette by nurse Tolarba is so important. First and
foremost, in this era of profound nursing shortages
and nationwide attempts to recruit nurses and pre-
vent burnout, the story as described above is a clas-
sic example of a situation that could easily lead to
strife, conflict, and burnout. The main reason most
of us went into health care was to help people, and
when we run into a situation in which the patient
is becoming abusive to the health care provider, how
that conversation is handled can make the differ-
ence between a meaningful interaction or yet
another person leaving the field of nursing.
One of the most important take-home messages
from Tolarba’s story is to remember that moment
of reflection after the hurtful sentence or sentences
have been said. Doing or saying the “right thing” at
that moment takes a profound level of courage and
maturity. Sometimes the patient is (perhaps on
purpose, perhaps not) attempting to poison the all-
important clinician-patient relationship, and we, as
consummate professionals, must rally the strength
to find the good in someone even as he or she may
be putting us down. This is often incredibly diffi-
cult to do, but as was so gracefully demonstrated in
this story, it can be done, and sometimes with
Tolarba did what we should all strive to do: to
see past the indignity, and to gently pull the kind
person out of the person who may be berating us.
We, as consummate professionals, must rally
the strength to find the good in someone even
as he or she may be putting us down.
About the Authors
Richard H. Savel is the physician coeditor of the American
Journal of Critical Care. He is the medical codirector of the
surgical intensive care unit at Montefiore Medical Center
and an associate professor of clinical medicine and neu-
rology at the Albert Einstein College of Medicine, both
in New York City. Cindy L. Munro is the nurse coeditor of
the American Journal of Critical Care. She is associate dean
for research and innovation at the University of South Florida,
College of Nursing, Tampa, Florida.
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We all care for patients and their families when
they are at their sickest and most stressed.
It is important that we remind ourselves of the asym-
metric nature of the relationship, and that we assume
all of our patients are good people who are very
sick and emotionally stressed. The technique that
he used was to “cure with a touch.” His technique
is powerful, but it takes a great deal of profession-
alism and maturity to go up to someone who has
just insulted you and tell them that despite the fact
that you have insulted me, I am going to rise above
it and provide you with the tender and professional
care that you deserve.
The most magical aspect of this nurse’s story
was that he not only retained his own dignity, but
in doing so (saying very little), he pointed out the
ridiculous and hurtful nature of the words initially
spoken by the patient. We wholeheartedly applaud
nurse Tolarba and any ICU clinician who has ever
responded well to a similar situation. He took a
painful circumstance—teetering on the brink of
disaster—and used training, professionalism, and
experience to provide highly dignified care for the
patient and to help maintain a dignified work envi-
ronment for all of us.
The most valuable element of this account is
that it can be applied to each and every ICU clini-
cian. We all care for patients and their families
when they are at their sickest and most stressed;
sometimes those families take their anxiety, frustra-
tion, and anger out on the team that has chosen to
help them. Stories like nurse Tolarba’s remind us
that what we do is extremely important, but often
incredibly challenging. This tale describes the true
essence of nursing: to care when it isn’t easy, to find
joy when others cannot, and to rise above the ordi-
nary and see the extraordinary.
The statements and opinions contained in this editorial
are solely those of the coeditors.
1.Baillie L. Patient dignity in an acute hospital setting: a case
study. Int J Nurs Stud. 2009;46(1):23-36.
2.Whitehead J, Wheeler H. Patients’ experiences of privacy
and dignity. Part 1: a literature review. Br J Nurs. 2008;
3.Woogara J. Patients’ rights to privacy and dignity in the
NHS. Nurs Stand. 2005;19(18):33-37.
4.Embriaco N, Papazian L, Kentish-Barnes N, Pochard F,
Azoulay E. Burnout syndrome among critical care health-
care workers. Curr Opin Crit Care. 2007;13(5):482-488.
5.Levy MM. Caring for the caregiver. Crit Care Clin. 2004;
6.Lowe J, Archibald C. Cultural diversity: the intention of
nursing. Nurs Forum. 2009;44(1):11-18.
7.Poncet MC, Toullic P, Papazian L, et al. Burnout syndrome
in critical care nursing staff. Am J Respir Crit Care Med.
8.Raggio B, Malacarne P. Burnout in intensive care unit.
Minerva Anestesiol. 2007;73(4):195-200.
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Richard H. Savel and Cindy L. Munro
The Essence of Nursing
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