Caring for dying children: a comparative study of nurses' experiences in Greece and Hong Kong

Challenges of paediatric palliative care in the intensive care unit during the COVID-19 pandemic

BACKGROUND

The integration of paediatric palliative care into the Iranian health system is essential.

AIMS

The aim of this study was to identify the challenges of palliative care in the paediatric intensive care unit during COVID-19 through the experiences of healthcare providers.

METHODS

A qualitative study with content analysis approach was conducted. Fifteen physicians and nurses were selected by purposeful sampling. The semi-structured, in-depth interviews were applied in the data collection.

FINDINGS

Ten main categories were extracted from data analysis, including 'caring in COVID-19', 'communication and family centre care', 'breaking bad news', palliative care training', 'pain and symptom management', 'support of the child, family and clinical team', 'physical environment', 'guidelines', 'specialised staff' and 'home based palliative care'.

CONCLUSION

Palliative care in the PICU faces several challenges, especially during COVID-19, but the clinical team are making every attempt to improve the comprehensive care of children and their families. Telehealth is important in COVID-19, and education is also a key component to improve palliative care in the PICU in Iran.

Knowledge of pediatric palliative care among medical students in Jordan: A cross-sectional study

Purpose

The aim of this study was to examine the medical student knowledge regarding pediatric palliative care (PPC) and determine the predictors of knowledge among them toward PPC.

Methods

A cross-sectional engaging study was directed with 326 medical students studying in Jordanian universities. A campaign utilizing online social media and Web-based software were executed to promote, enlist, overview undergraduate medical students, and gather information for this study. The authors employed four techniques to select undergraduate medical students on paid-promoted Facebook, personal messages, and postings in clinical forums.

Results

The results of this study showed that medical students have inadequate knowledge about pediatric palliative care in Jordan. The only factors that predict the knowledge toward PPC is gender.

Conclusion

it should build the medical students' information on pediatric palliative care. The pointer was not significant in the multivariate studies, and that vicariate studies indicated no distinction in the overall scores on either test among the nonmedical students, Training projects ought to be established and delivered to pediatric medical students to improve their knowledge about pediatric palliative/palliative consideration.

Experiences of new nurses dealing with death in a paediatric setting: A descriptive qualitative study

AIMS

To explore and describe the experiences, challenges and coping strategies of new nurses dealing with paediatric death in a clinical setting.

DESIGN

A descriptive qualitative study design was used.

METHODS

Semi-structured interviews were conducted to explore the experiences of 12 new paediatric nurses from a tertiary public hospital in Singapore. Data were collected from September 2019-December 2019. A thematic analysis was performed for data analysis.

RESULTS

Four themes were generated: (a) a spectrum of emotions; (b) the 'blame' game; (c) getting through the grief; and (d) new nurses' wish list. The new nurses tended to be emotionally affected by their first death experience. They felt anxious and personally responsible for the death but eventually controlled their emotions. Colleagues, religion and self-actualization were key in overcoming grief.

CONCLUSION

The experiences nurses go through at the early stages of their profession shape future workplace attitudes. Additional training and support should be provided to new nurses to build their confidence in managing end-of-life care. Training should include cultural awareness and communication skills to equip nurses with the necessary skills.

IMPACT

This research will have an impact on institutions, which develop culturally congruent training and support platforms that prepare new nurses for nursing practice. This research will drive future investigations on the long-term effects of paediatric death on new nurses.

Health professionals' experiences of grief associated with the death of pediatric patients: a systematic review

OBJECTIVE

The objective of this review was to synthesize the experiences of health professionals who have experienced grief as a result of a pediatric patient dying.

INTRODUCTION

There has been some research into health professionals' grief experiences associated with the death of pediatric patients, but there has not been a review that synthesizes the findings of these experiences. Other related reviews have focused on prenatal, perinatal or adult deaths or the coping strategies employed by health professionals. This review highlights the complexities of experiences faced by pediatric health professionals.

INCLUSION CRITERIA

Qualitative studies involving pediatric health professionals working in any healthcare setting who had experienced grief from the death of a patient were considered for inclusion. Studies were conducted in any country, at any time and published in English.

METHODS

The search was conducted in PubMed, CINAHL, Embase, PsycINFO, Scopus and ProQuest Dissertations and Theses. The search was completed in January 2019. The review followed principles of meta-aggregation in line with the JBI approach. Methodological quality assessment was based on representation of participants' voices and congruence between research methodology and both research question and analysis of data.

RESULTS

Meta-aggregation led to three synthesized findings from 12 qualitative studies that met the inclusion and methodological quality criteria. Studies predominantly included nurses working in a hospital, with sample sizes ranging from six to 25 participants. The synthesized findings were physical, behavioral, psychological or spiritual symptoms; compounding grief; and alleviating grief. Physical, behavioral, psychological, or spiritual symptoms highlighted the various characteristics of grief experiences by health professionals. Compounding grief was the largest synthesized finding and incorporated the various factors that contributed to a poorer experience of grief. Alleviating grief showed the limited identified factors that improved the experience of grief. Methodological quality led to synthesized findings receiving a ConQual rating of low or moderate.

CONCLUSIONS

The synthesized findings from this review highlight the varied reported experiences of grief in health professionals. The methodological quality and reporting of studies, however, led to decreased confidence in the synthesized findings and recommendations arising from this review. Healthcare professionals should be aware of the potential for experiencing grief when a patient dies and the compounding and alleviating factors associated with this. Further research could expand participant and language limitations, and improve methodological quality and reporting.

New Directions in Pediatric Palliative Care Education for Preclinical Medical and Nursing Students

OBJECTIVES

Since insufficient education has partially contributed to challenges in providing pediatric palliative care (PPC), a cross-sectional questionnaire study was conducted to explore the knowledge, attitudes, and educational needs of preclinical medical and nursing students in Hong Kong.

METHODS

Pretested self-administered 44-item questionnaires with written informed consent were distributed to 241 medical and nursing students at Li Ka Shing Faculty of Medicine, the University of Hong Kong, between February and March 2019. This questionnaire covered eleven categories related to participants' knowledge of and attitudes towards PPC. A convenience sampling method was used. Data analysis was performed with descriptive statistics, chi-squared, and Fisher's exact test.

RESULTS

Only 38.3% of participants had heard of PPC before, but 73.5% advocated for its local commencement. A large number, with more in nursing, misunderstood fundamental palliative concepts and pain assessment methods. Many reported that undergraduate curricula should include PPC since they were not prepared to deal and cope with dying children. More medical students identified multidisciplinary approaches in PPC while less believed that they were mentally prepared to discuss death and dying. The majority indicated family as the final decision maker, even for teenage patients. Although a large proportion agreed that PPC should be delivered at home since the diagnosis of a life-limiting illness, only a few were aware of the suggested referral structure.

CONCLUSIONS

Most healthcare students were supportive of PPC despite their limited exposure. PPC education on palliative principles, pain management, multidisciplinary approaches, and emotional coping skills is needed and welcomed among students.

Experience of nurses who work with children with palliative care needs: A mixed-method systematic review

OBJECTIVE

The importance of palliative care education for nurses has been recognized worldwide. The study aims to explore the experiences of nurses working with children with palliative care needs and to identify any related educational needs.

METHODS

The electronic databases of CINAHL, Cochrane, PubMed, OVID, Social Care Online, Web of Science, Scopus, and ProQuest were searched for the period 2000-2015.

RESULTS

Finding revealed that working with children with palliative care needs is an emotionally struggling job for nurses, especially when they try to manage the transition of pediatric patients from curative to palliative care. Staffing level and time constraints comprise a major obstacle in pediatric palliative care. Focusing on invasive treatment and technology in spite of the feelings that it will not improve patients' health status intensifies the feeling of guilt and helplessness for nurses. Finally, nurses asserted the importance of receiving pediatric palliative care education, especially how to communicate with children with palliative care needs and their families.

SIGNIFICANCE OF RESULTS

Further research is recommended with regard to nurses' experience in communication with children with palliative care needs. Nursing education in pediatric palliative care is significantly important, especially how to communicate with children with palliative care needs and their families.

Nurses' Perspective on Caring for Women Experiencing Perinatal Loss

PURPOSE

The purpose of this study was to describe the experience of caring for women with a perinatal loss from the perspective of the nurse and to determine the extent to which the response to perinatal loss reflects a process.

STUDY DESIGN AND METHODS

A purposive study was conducted with nine labor and birth nurses with experience in caring for women with a perinatal loss. The nurses were from two acute care hospitals within one healthcare system in Southeastern Massachusetts. A qualitative descriptive design with in-depth interviewing based on was used to gather and analyze data.

RESULTS

Several themes depicting nurses' experience were identified: struggling with emotions, carrying on in the moment, being present for the patient, expressing conflict, and taking care of self. A process was identified by nurses describing their response to perinatal loss. The process began with recognition of the loss and progressed through phases including the recognition of their emotional impact, connecting with the mother, dealing with emotions, acting professionally, preparing to return to work, and never forgetting the woman.

CLINICAL IMPLICATIONS

Nurses identified a need for more education and managerial support for excellence in care of women with a perinatal loss. Education to prepare nurses to meet the physical, psychological, and spiritual needs of women is recommended. Debriefing after caring for a woman with a loss was suggested by the nurses. When nurses' needs are met, they are better prepared to care for women experiencing a perinatal loss.

The Practice of Mutual Protection in the Care of Children with Palliative Care Needs: A Multiple Qualitative Case Study Approach from Jordan

PURPOSE

This study explores the experience of disclosing critical information in the care of children with palliative care needs, from the perspective of physicians, nurses, and mothers in Jordan.

DESIGN AND METHODS

This study employed a qualitative case study approach. It was conducted in three paediatric units in a Jordanian hospital. Each case comprised a child aged 1-12 years with a condition eligible for palliative care who received health care in one of these units, and their most involved carers (e.g. mother, physician and nurse). Two data collection methods were employed: participant observation and semi-structured interviews with three categories of participants: mothers, physicians, and nurses. Ethical approval was obtained from the hospital ethical review board. Written consent was obtained from all participants.

RESULTS

Qualitative case studies were developed around 15 children (aged 1-12 years, nine were boys and six were girls, with varying diagnoses: renal disease, neurological conditions, and congenital heart defects). A total of 197 observational hours and 60 interviews were completed (15 mothers, 12 physicians and 21 nurses). The findings demonstrate that the practice of 'mutual protection' dominated communication between children, parents and clinical staff. Parents protected their children by disclosing only partial information about their disease, and by avoiding any information they thought would cause the child distress or loss of hope. Similarly, children avoided expression to their parents of their anxieties or fears, in order to protect them. In turn, nurses attempted to ensure observance of professional boundaries with children and mothers to avoid a sense of loss when a child died.

CONCLUSION

The findings of the current study indicate that while open and honest communication between parents and children is generally recommended by literature, not all mothers agree with adopting open communication with their children concerning their illnesses. Therefore, any future intervention planned for them should respect parents' autonomy and decisions in addition to their cultural backgrounds.

PRACTICAL IMPLICATIONS

The provision of ongoing education and specialised training for professionals to provide them with culturally sensitive skills in communication and provision of emotional support for children and parents is needed to improve clinical practice in healthcare settings with limited access to specialist palliative care such as Jordan.

Health professionals' experiences of grief associated with the death of pediatric patients: a qualitative systematic review protocol

REVIEW QUESTION

What are health professionals' experiences of grief associated with the death of pediatric patients in acute or community healthcare settings?

Perceived challenges in pediatric palliative care among doctors and nurses in Hong Kong

This study aims to examine perceived challenges, including knowledge, skills, self, and work environment, of professionals in providing pediatric palliative care (PPC) in Hong Kong and the differences in perceived challenges between groups. A total of 680 pediatric doctors and nurses participated in the survey. They tended to perceive the provision of PPC as difficult and considered "advanced skills" (those dealing with death-related issues) challenging. Findings indicate that nurses, professionals who are less experienced, do not have children, and have not received palliative care training perceived a higher level of challenges in providing PPC. Implications for training and support are discussed.

“We Take Care of People; What Happens to Us Afterwards?”: Home Health Aides and Bereavement Care in Hospice

After a hospice patient dies, hospice providers can experience a variety of emotional responses. While work has been done on social workers’ and nurses’ reactions to patient death, home health aides (HHAs) have been overlooked. To address this gap, we conducted focus groups and individual qualitative interviews with 14 hospice HHAs. Questions covered HHAs’ grief responses and how they coped with grief. We found a high burden of grief reactions; many HHAs often developed very close patient relationships. HHAs also noted that they often started working with new patients almost immediately after a death, leaving little time to process the loss. However, HHAs found support from other HHAs, their supervisors, as well as family, friends, and spiritual practices to be helpful in coping with their grief. Future work should enhance support to HHAs around patient loss; for example, grief support may be embedded into hospice team activities.

Maintaining Integrity: How Nurses Navigate Boundaries in Pediatric Palliative Care

PURPOSE

To explore how nurses manage personal and professional boundaries in caring for seriously ill children and their families.

DESIGN AND METHODS

Using a constructivist grounded theory approach, a convenience sample of 18 registered nurses from four practice sites was interviewed using a semi-structured interview guide.

RESULTS

Nurses across the sites engaged in a process of maintaining integrity whereby they integrated two competing, yet essential, aspects of their nursing role - behaving professionally and connecting personally. When skillful in both aspects, nurses were satisfied that they provided high-quality, family-centered care to children and families within a clearly defined therapeutic relationship. At times, tension existed between these two aspects and nurses attempted to mitigate the tension. Unsuccessful mitigation attempts led to compromised integrity characterized by specific behavioral and emotional indicators. Successfully mitigating the tension with strategies that prioritized their own needs and healing, nurses eventually restored integrity. Maintaining integrity involved a continuous effort to preserve completeness of both oneself and one's nursing practice.

CONCLUSIONS

Study findings provide a theoretical conceptualization to describe the process nurses use in navigating boundaries and contribute to an understanding for how this specialized area of care impacts health care providers.

PRACTICE IMPLICATIONS

Work environments can better address the challenges of navigating boundaries through offering resources and support for nurses' emotional responses to caring for seriously ill children. Future research can further refine and expand the theoretical conceptualization of maintaining integrity presented in this paper and its potential applicability to other nursing specialties.

The emergence of personal growth amongst healthcare professionals who care for dying children

Objective:

Compassion fatigue, burnout, and vicarious traumatization are prominent topics in the current literature on the impact of the rewarding but challenging work of healthcare professionals who care for patients with life-limiting illnesses. The positive effects of caregiving constitute a newly emerging outcome that has been relatively unexplored in the pediatric literature, and yet they may play an important role in contributing to the satisfaction and well-being of the healthcare professionals who care for children who have a life-limiting illness.

Method:

This paper reports the results of a secondary analysis of qualitative interview transcripts that explored the experiences of hospital-based pediatric healthcare providers caring for children with varied life-limiting illnesses. In-depth qualitative interviews were conducted with 25 healthcare professionals (9 social workers, 8 nurses, and 8 physicians). The majority of participants were women (80%), with an age range between 20 and 60 years, and most (84%) had the experience of caring for more than 15 dying children. Thematic analysis was conducted using interpretive description and constant comparison.

Results:

Every healthcare professional interviewed experienced personal growth as a result of their providing care for dying children. Three dimensions of personal growth were most consistently reported: (1) new or altered life perspectives, (2) enhanced personal resources, and (3) benevolence.

Significance of results:

A deeper understanding of the phenomenon of personal growth could help healthcare organizations to implement innovative approaches that would counterbalance compassion fatigue, and thereby enhance both healthcare provider well-being and child and family outcomes.

Home-Based Palliative Care for Children With Incurable Cancer: Long-term Perspectives of and Impact on General Practitioners

CONTEXT

Although a large percentage of children with advanced-stage cancer die at home, remarkably little information is available regarding the experience of general practitioners (GPs) with respect to providing home-based palliative care to children with incurable cancer.

OBJECTIVES

The objective of this study was to explore the perspectives of GPs who care for children with advanced-stage cancer in a home-based setting.

METHODS

In this cross-sectional study, 144 GPs who provided home-based palliative care to 150 children with incurable cancer from 2001 through 2010 were invited to complete a questionnaire addressing their perspectives regarding: 1) symptom management, 2) collaboration with other health care professionals, 3) the child's death and care after death, and 4) impact of having provided palliative care, scored on distress thermometer (range 0-10).

RESULTS

A total of 112 GPs (78%) responded, and 91 GPs completed the questionnaire for 93 patients. The median interval between the child's death and completing the questionnaire was seven years. The most prevalent symptoms reported in the patients were fatigue (67%) and pain (61%). Difficulties with communicating with (14%), coordinating with (11%), collaborating with (11%), and contacting (2%) fellow members of the multidisciplinary treatment team were rare. Hectic (7%) and shocking (5%) situations and panic (2%) around the child's death were rare. GPs reported feelings of sadness (61%) and/or powerlessness (43%) around the time of the patient's death, and they rated their own distress level as relatively high during the terminal phase (median score 6, range 0-9.5). The majority of GPs (94%) reported that they ultimately came to terms with the child's death.

CONCLUSION

In general, GPs appear to be satisfied with the quality of home-based palliative care that they provide pediatric patients with incurable cancer. Communication among health care professionals is generally positive and is considered important. Finally, although the death of a pediatric patient has a profound impact on the GP, the majority of GPs eventually come to terms with the child's death.

The experience of providing end of life care at a children's hospice: a qualitative study

Background

More attention is being paid to the wellbeing of staff working in stressful situations. However, little is known about staff experience of providing end-of-life care to children within a hospice setting. This study aims to explore the experiences of care team staff who provide end-of-life care within a children’s hospice.

Methods

Qualitative research incorporating interviews and a focus group. Data were analysed using thematic analysis. Purposeful sampling led to a total of 15 care team staff recruited from a children’s hospice offering palliative and specialist care to life-limited children and young people.

Results

The hospice setting provides a model of excellence in supporting staff and mitigating challenging aspects of their role, which includes peer/organisational support, and regular ongoing training in key aspects of children’s palliative care. Key recommendations for improving their experience included advanced communication training and knowledge sharing with other children’s palliative care specialists within the acute setting.

Conclusions

Service and policy initiatives should encourage open, informal peer/organisational support among the wider children’s palliative care sector. Further research should focus on paediatric palliative care education, particularly in relation to symptom management and communication at end-of-life, harnessing the expertise and breadth of knowledge that could be shared between children’s hospices and hospital settings.

Electronic supplementary material

The online version of this article (doi:10.1186/s12904-017-0189-9) contains supplementary material, which is available to authorized users.

Healthcare staff 's experience in providing end-of-life care to children: A mixed-method review

BACKGROUND

Staff who provide end-of-life care to children not only have to deal with their own sense of loss but also that of bereaved families. There is a dearth of knowledge on how they cope with these challenges.

AIM

The aim of this review is to explore the experiences of healthcare professionals who provide end-of-life care to children in order to inform the development of interventions to support them, thereby improving the quality of paediatric care for both children and their families.

DATA SOURCES

Searches included CINAHL, MEDLINE, Web of Science, EMBASE, PsychINFO and The Cochrane Library in June 2015, with no date restrictions. Additional literature was uncovered from searching reference lists of relevant studies, along with contacting experts in the field of paediatric palliative care.

DESIGN

This was a systematic mixed studies review. Study selection, appraisal and data extraction were conducted by two independent researchers. Integrative thematic analysis was used to synthesise the data.

RESULTS

The 16 qualitative, 6 quantitative and 8 mixed-method studies identified included healthcare professionals in a range of settings. Key themes identified rewards and challenges of providing end-of-life care to children, the impact on staff's personal and professional lives, coping strategies and key approaches to help support staff in their role.

CONCLUSION

Education focusing on the unique challenges of providing end-of-life care to children and the importance of self-care, along with timely multidisciplinary debriefing, are key strategies for improving healthcare staff's experiences, and as such the quality of care they provide.

Pediatric oncologists' coping strategies for dealing with patient death

This research examined pediatric oncologists coping strategies when their patients died of cancer. Twenty-one pediatric oncologists at 2 Canadian pediatric academic hospitals were interviewed about their coping strategies when patients died or were in the process of dying. The grounded theory method of data collection and data analysis were used. Line-by-line coding was used to establish codes and themes and constant comparison was used to establish relations among emerging codes and themes. Pediatric oncologists used engagement coping strategies with primary and secondary responses including emotional regulation (social support and religion), problem solving (supporting families at end of life), cognitive restructuring (making a difference and research), and distraction (breaks, physical activity, hobbies and entertainment, spending time with own children). They also used disengagement coping strategies that included voluntary avoidance (compartmentalization and withdrawing from families at end of life). Given the chronic nature of patient death in pediatric oncology and the emotionally difficult nature of this work, medical institutions such as hospitals have a responsibility to assist pediatric oncologists in coping with this challenging aspect of their work. Future research is needed to evaluate how best to implement these changes on the institutional level to help oncologists cope with patient death and the effect of using these strategies on their quality of life.

Grief reactions and impact of patient death on pediatric oncologists

BACKGROUND

To examine pediatric oncologists' grief reactions to patient death, and the impact patient death has on their personal and professional lives.

PROCEDURE

The grounded theory method was used. Data was collected between March 2012 and July 2012 at two academic centres in Canada. Twenty-one out of 34 eligible pediatric oncologists at different stages of their career were recruited and interviewed about their experiences with patient death. Inclusion criteria were: being able to speak English and having had a patient die in their care. The participants formed three groups of oncologists at different stages of career including: fellows, junior oncologists, and senior oncologists who varied in sub-specialties, gender, and ethnicities.

RESULTS

Pediatric oncologists reported a range of reactions to patient death including sadness, crying, sleep loss, exhaustion, feeling physically ill, and a sense of personal loss. They also reported self-questioning, guilt, feelings of failure and helplessness. The impact of these deaths had personal consequences that ranged from irritability at home, feeling disconnected from family members and friends, and becoming more desensitized towards death, to gaining a greater and more appreciative perspective on life. Professional impacts included concern about turnover or burnout at work and improving holistic care as a result of patient deaths.

CONCLUSIONS

Grief over patient death and the emotional labour involved in these losses are a robust part of the pediatric oncology workplace and have major impacts on pediatric oncologist's personal and professional lives. Interventions that focus on how to help pediatric oncologists deal with these reactions are needed.

Cultural Influences in Pediatric Cancer

Objective: To review the literature on cultural factors influencing clinical care and family management of pediatric cancer. Methods: A literature review including 72 articles related to cultural issues in pediatric cancer was conducted. Information was organized around several clinically driven themes. Results: Cultural factors influenced many aspects of the cancer experience including illness representations, reaction to diagnosis, illness disclosure patterns, complementary and alternative medicine use, management of medical procedures, coping strategies, and end of life issues. Conclusion: Increased awareness of cultural factors is needed to improve clinical care and reduce health disparities. Specific strategies to approach cultural differences are provided to enhance patient and family care from diagnosis to cure/end of life.

The challenge to health professionals when carers resist truth telling at the end of life: a qualitative secondary analysis

AIMS AND OBJECTIVES

To draw out the similar complexities faced by staff around truth-telling in a children's and adult population and to interrogate the dilemmas faced by staff when informal carers act to block truth-telling.

BACKGROUND

Policy encourages normalisation of death, but carers may act to protect or prevent the patient from being told the truth. Little is known about the impact on staff.

DESIGN

Secondary analysis of data using a supra-analysis design to identify commonality of experiences.

METHODS

Secondary 'supra-analysis' was used to transcend the focus of two primary studies in the UK, which examined staff perspectives in a palliative children's and a palliative adult setting, respectively. The analysis examined new theoretical questions relating to the commonality of issues independently derived in each primary study. Both primary studies used focus groups. Existing empirical data were analysed thematically and compared across the studies.

RESULTS

Staff reported a hiding of the truth by carers and sustained use of activities aimed at prolonging life. Carers frequently ignored the advance of end of life, and divergence between staff and carer approaches to truth-telling challenged professionals. Not being truthful with patients had a deleterious effect on staff, causing anger and feelings of incompetence.

CONCLUSIONS

Both children's and adult specialist palliative care staff found themselves caught in a dilemma, subject to policies that promoted openness in planning for death and informal carers who often prevented them from being truthful with patients about terminal prognosis. This dilemma had adverse psychological effects upon many staff.

RELEVANCE TO CLINICAL PRACTICE

There remains a powerful death-denying culture in many societies, and carers of dying patients may prevent staff from being truthful with their patients. The current situation is not ideal, and open discussion of this problem is the essential first step in finding a solution.

A whole-hospital approach? Some staff views of a hospital bereavement care service

A qualitative study was conducted to address staff's views of bereavement care in a large hospital setting. Two focus-groups and 1 interview were attended by 21 self-selected staff. The qualitative analysis yielded the following: (a) a staff training program within a structured bereavement care service may give staff a sense of confidence and pride in this aspect of their work; (b) a whole-hospital approach to bereavement care may offer an alternative model to individual clinical services; (c) the question is raised as to whether the presence of a bereavement co-ordinator helps contain staff anxiety and other painful emotions generated by contact with the dying and bereaved; and (d) the potential role of ancillary staff in bereavement care warrants more study.

Revealing the Meaning of the Mourning Process of Pediatric Nurses Facing the Death of Cancer Patients

Objetivo: develar el significado del duelo en enfermeras(os) que enfrentaron la muerte de niños con cáncer. La muerte de un niño(a) por cáncer genera un gran impacto en el equipo de enfermería, lo que produce impotencia, frustración y pena, que pueden llegar a causar Burnout. Método: se utilizó la investigación cualitativa fenomenológica basada en Husserl; se recogió la experiencia de diez enfermeras(o) oncológicas(os) pediátricas que enfrentaron la muerte de pacientes con cáncer bajo su cuidado. Los datos se obtuvieron de junio a noviembre del 2011 con entrevistas en profundidad grabadas y transcritas literalmente. El análisis fenomenológico se realizó según el método de Streubert. Resultado: los testimonios entregados develaron tres unidades de significado: las enfermeras vivencian la muerte de un paciente a través del transitar entre su propia forma de enfrentar la muerte y el cuidado profesional que otorgan. Con ello aparece un aprendizaje de vida dado por la comprensión de lo que es trabajar en oncología y los vínculos que establece en este ámbito. Esto permite desarrollar un cuidado con un sello particular. Conclusión: el estudio concluye que las enfermeras experimentan el duelo como un proceso dinámico al que atribuyen sentido a través de la entrega de un cuidado amoroso.

Reactions to patient death: the lived experience of critical care nurses

A qualitative study using phenomenological descriptive design was conducted to explore critical care nurses' experiences with patient death. Several themes emerged as a result of this study: coping, personal distress, emotional disconnect, and inevitable death. Understanding critical care nurses' reactions to patient death may help to improve the care provided to critically ill dying patients and their families and to meet the needs of the nurses who care for them.

Being an Expert Nurse in Pediatric Oncology Care

Pediatric oncology has become a highly specialized area, and the transition from novice nurse to expert can be complicated. The aim of this study was to describe the perceptions of nurses in pediatric oncology regarding the role of an expert nurse in pediatric oncology. Nurses (n = 66) working in pediatric oncology participated by writing their narratives. The data were analyzed by means of content analysis, and 3 categories were found: an expert has confidence in his or her knowledge, an expert provides high-quality care, and an expert is given possibilities for professional growth. It can be concluded that when nurses are given possibilities for continuous education and reflection, and have a feeling of satisfaction at being able to fulfill a child and his or her family’s needs, this enhances their possibility to become experts and maintain expert competence.

Caring for dying and meeting death: experiences of Iranian and Swedish nurses

Objective:

Our world is rapidly becoming a global community, which creates a need to further understand the universal phenomena of death and professional caring for dying persons. This study thus was conducted to describe the meaning of nurses’ experiences of caring for dying people in the cultural contexts of Iran and Sweden.

Materials and Methods:

Using a phenomenological approach, phenomenon of caring for dying people was studied. Eight registered nurses who were working in oncology units in Tehran, Iran and eight registered nurses working in hospital and home care in North part of Sweden were interviewed. The interviews were analyzed using the principles of phenomenological hermeneutics.

Results:

The findings were formulated based on two themes included: (1) “Sharing space and time to be lost”, and (2) “Caring is a learning process.

Conclusions:

The results showed that being with dying people raise an ethical demand that calls for personal and professional response, regardless of sex, culture or context. The physical and organizational context must be supportive and enable nurses to stand up to the demands of close relationships. Specific units and teamwork across various personnel seem to be a solution that is missing in Iran.

Pediatric palliative care provision around the world: a systematic review

Pediatric palliative care is recommended by many organizations. Yet, there is no information available on the progress that has been made in providing this care or the gaps that still exist in provision around the world. We conducted a systematic review to address this gap in knowledge. The systematic review identified 117 peer-reviewed and non-peer reviewed resources. Based on this information, each country was assigned a level of provision; 65.6% of countries had no known activities, 18.8% had capacity building activities, 9.9% had localized provision, and 5.7% had provision that was reaching mainstream providers. Understanding the geographic distribution in the level of provision is crucial for policy makers and funders.

Creating a curtain of protection: nurses' experiences of grief following patient death

PURPOSE

To describe the lived experience of nurses surrounding the death of their patients.

DESIGN

A qualitative phenomenologic approach was used for the interview and analysis framework. Methods to ensure trustworthiness and rigor were incorporated into the design.

METHODS

Using semistructured interviews and phenomenologic concepts, the investigators interviewed 11 registered nurses where data was analyzed using methods of Heideggerian hermeneutical analysis and van Manen's progression of reflection, description, writing, and rewriting.

FINDINGS

Four themes were identified: (a) Reciprocal relationship transcends professional relationship; (b) initial patient death events are formative; (c) nurses' coping responses incorporate spiritual worldviews and caring rituals; and (d) remaining "professional" requires compartmentalizing of experience.

CONCLUSIONS

Nurses create a curtain of protection to mitigate the grieving process and allow them to continue to provide supportive nursing care.

CLINICAL RELEVANCE

By developing understanding of the grieving and coping processes, nursing faculty, administrators, and leaders can provide better learning opportunities and more supportive practice environments for the professional nurse.

Burnout, psychiatric morbidity, and work-related sources of stress in paediatric oncology staff: a review of the literature

OBJECTIVE

A growing body of research suggests that staff working in adult oncology services are at risk of burnout and psychiatric morbidity, but whether or not these findings can be generalised to staff working in paediatric oncology is questionable. This paper reports the findings of a comprehensive review of the literature on burnout, psychiatric morbidity, and sources of work-related stress in paediatric oncology staff.

METHODS

Electronic searches of MEDLINE and PSYCHINFO. This was followed by a screening process, during which papers where checked against inclusion and exclusion criteria, and the quality of study reporting was assessed. Information about the study design and methods was then extracted from each paper so that the methodological quality could be critiqued.

RESULTS

Ten studies meeting the review inclusion criteria were identified. No studies were identified which compared paediatric and adult oncology staff. Research on paediatric oncology staff has failed to use the well-established standardised measures of burnout and psychiatric morbidity employed in studies of adult oncology staff. There is some qualitative evidence to suggest paediatric oncology nurses experience a unique, additional set of stressors not encountered by colleagues in adult oncology services.

CONCLUSION

The evidence on stress and burnout in paediatric oncology staff is extremely limited. In order to devise appropriate and effective interventions to support staff, we need to have a much better understanding of the level of burnout and psychiatric morbidity experienced by all members of the paediatric oncology multi-disciplinary team, as well as the factors that contribute to these experiences.

Impact of a contemplative end-of-life training program: Being with dying

Objective:

Health care professionals report a lack of skills in the psychosocial and spiritual aspects of caring for dying people and high levels of moral distress, grief, and burnout. To address these concerns, the “Being with Dying: Professional Training Program in Contemplative End-of-Life Care” (BWD) was created. The premise of BWD, which is based on the development of mindfulness and receptive attention through contemplative practice, is that cultivating stability of mind and emotions enables clinicians to respond to others and themselves with compassion. This article describes the impact of BWD on the participants.

Methods:

Ninety-five BWD participants completed an anonymous online survey; 40 completed a confidential open-ended telephone interview.

Results:

Four main themes—the power of presence, cultivating balanced compassion, recognizing grief, and the importance of self-care—emerged in the interviews and were supported in the survey data. The interviewees considered BWD's contemplative and reflective practices meaningful, useful, and valuable and reported that BWD provided skills, attitudes, behaviors, and tools to change how they worked with the dying and bereaved.

Significance of results:

The quality of presence has the potential to transform the care of dying people and the caregivers themselves. Cultivating this quality within themselves and others allows clinicians to explore alternatives to exclusively intellectual, procedural, and task-oriented approaches when caring for dying people. BWD provides a rare opportunity to engage in practices and methods that cultivate the stability of mind and emotions that may facilitate compassionate care of dying patients, families, and caregivers.

End-of-life experiences in adolescents dying with cancer

PURPOSE

This study explores the experiences of individuals in early, middle, and late adolescence dying from cancer. Place of death, medications used at end of life (EOL), and discussions prior to death are examined.

METHODS

Data were obtained from a retrospective review of medical charts from 103 adolescents who died of cancer between 2000 and 2005.

RESULTS

Adolescents with leukemia/lymphoma were relatively more likely to die in an intensive care unit (p = 0.028) where cause of death was more likely to be treatment-related (p < 0.001), and EOL discussions more likely to occur in the last 7 days of life (p = 0.002). Anxiolytic use was significantly higher during late adolescence (p = 0.037).

CONCLUSIONS

Adolescents have unique developmental needs that should be considered at EOL. Timing of EOL discussions occurred very close to death for a significant number of adolescents, allowing very little time to psychologically prepare for death.

Pediatric Oncology Nurses' Management of Patients' Symptoms

The purpose of this article is to describe the results of a national descriptive survey of 509 pediatric oncology nurses' interventions for managing patients'symptoms. The Nurses' Distress and Interventions for Symptoms Survey (NDISS) is used to assess nurses' management of patients' 7 most distressing symptoms. The average number of symptoms reported as being present is 6.0 (SD 1.3; range, 0-7). Pain is the most commonly reported symptom; trouble sleeping is the least common. The mean score for nurses' distress is 2.9 (SD 0.8; range, 0-4); nurses' distress is greatest with trouble sleeping and lowest with hair loss. Nurses use an average of 12.7 interventions to treat each symptom; pain has the greatest number of interventions to treat and hair loss the least. The average perceived effectiveness of interventions across symptoms is 2.5 (SD 0.5; range, 0-4). Pain is perceived as the most effectively treated symptom; fatigue is the least.

Relationship Between Pediatric Oncology Nurses' Management of Patients' Symptoms and Job Satisfaction

The purpose of this article is to describe the results of a study examining the relationship between nurses' management of pediatric oncology patients' symptoms and job satisfaction. Surveys were mailed to a national sample of pediatric oncology nurses to assess the presence of symptoms in their patients, the nurses' distress from the patients' symptoms, the interventions used to manage the symptoms, the perceived effectiveness of the interventions, and the nurses' job satisfaction. Based on the stress response sequence model, study hypotheses proposed that nurses' symptom management affects nurses' distress and, in turn, job satisfaction. Hierarchical regression analyses were used to evaluate the hypotheses and study model. Results demonstrated that both the number of nursing interventions and the perceived effectiveness of nursing interventions were significant as mediators in predicting nurses' distress. The overall study model contributed significantly in predicting overall job satisfaction.

A phenomenological study to understand the experiences of nurses with regard to brainstem death

METHOD

In this study six nurses from general intensive care units were interviewed. The resulting transcripts were analysed using hermeneutic phenomenology.

FINDINGS

The findings fall into five categories, feelings, communication, protection, education, and technology. Nurses appear to suffer a degree of cognitive dissonance that both adds to their stress and leads to difficulties in explaining brainstem death to relatives.

CONCLUSION

Nurses need more education and support to enable them to overcome cognitive dissonance and so give relatives honest information. Verbal information should be supplemented with a written information leaflet given to all relatives.

Peer-Supported Storytelling for Grieving Pediatric Oncology Nurses

Telling stories about deceased patients to supportive peers is frequently mentioned as an activity used for meaning-making in anecdotal reports of clinical practice and the literature addressing nurses' experiences caring for dying children. This study examines peer-supported storytelling for grieving pediatric oncology nurses using a mixed methods single-group descriptive repeated measures design. Participants were 6 registered nurses from a tertiary care pediatric hospital inpatient oncology unit who self-identified as experiencing grief. Participants met in self-selected dyads for 2 storytelling sessions. Questionnaires were completed at baseline, midpoint, and study end. Sessions were audio-recorded. Participants reported (1) receiving and providing support during sessions; (2) that sessions had an impact on their grief; (3) that sessions had an impact on their meaning-making, and the explicit session focus on making sense of and identifying benefit in their experiences was particularly helpful. There was a significant positive correlation between participant report of number of special patient deaths during career and impact of sessions on grief.

Paediatric palliative care: challenges and emerging ideas

Paediatric palliative care is an emerging subspecialty that focuses on achieving the best possible quality of life for children with life-threatening conditions and their families. To achieve this goal, the individuals working in this field need to: clearly define the population served; better understand the needs of children with life-threatening conditions and their families; develop an approach that will be appropriate across different communities; provide care that responds adequately to suffering; advance strategies that support caregivers and health-care providers; and promote needed change by cultivating educational programmes. Despite these challenges, advances in paediatric palliative care have been achieved in a short period of time; we expect far greater progress as the field becomes more formalised and research networks are established.

“It's Not a Job; It's a Lifestyle”: The Experience of Being a Donation Coordinator

Lifesaving organ transplantations cannot be performed without the donation of organs from another human being. The donation coordinator in an organ procurement organization has the responsibility of coordinating this “gift of life”—a highly stressful, but inherently rewarding occupation. Although numerous studies have examined the medical and social implications of organ donation, little has been written about the experiences of donation coordinators. This qualitative study examines the experiences of donation coordinators at a large metropolitan organ procurement organization, to understand how they perform under stress, the ways that they cope with this stress, and the meaning that they attribute to their roles. Implications for organ procurement organizations are discussed to assist such organizations in recruiting donation coordinators and in developing supportive interventions for current employees. Suggestions to help donation coordinators maintain good mental health are also offered.

Factors related to the psychological well-being of parents of children with leukemia in China

This study investigates factors correlated with the psychological well-being of parents of children with leukemia in China. A survey with self-administered questionnaires was employed and a total of 31 caregivers were recruited from two children's hospitals in Shanghai. The study investigates factors from three different aspects in the context of childhood cancer: children's illness-related and demographic variables, demographic variables of the parents, and the parents' coping approaches. The findings show that parents are at risk of poor psychological well-being related to perceived unsatisfactory financial status, and a lack of self-oriented coping approaches. The implications for social service provision are discussed.

Caregivers in death, dying, and bereavement situations

This document examines issues related to the work of both formal and informal caregivers as they are involved in caring for dying and/or bereaved individuals. The examination is organized around five central questions: what brings individuals to this work?; what enables them to develop effective caregiving relationships?; what sustains them in their work?; what responsibilities do they have to themselves and to others?; and how are they are influenced by the social context of their work? The goal of this article is to help individuals and teams improve the care they provide in death-related situations, while also assisting educators, managers, and administrators to prepare and support these caregivers in more effective ways.

Interdisciplinary Interventions To Improve Pediatric Palliative Care and Reduce Health Care Professional Suffering

OBJECTIVE

To implement and evaluate a quality improvement program of interdisciplinary palliative care education and support intended to increase the competence, confidence and ability to manage personal grief of health care professionals caring for dying children.

SETTING

A children's hospital in an urban academic medical center.

PARTICIPANTS

Pediatric health care professionals of all disciplines caring for children with life-threatening conditions.

INTERVENTIONS

We initiated a quality improvement program of professional education and support consisting of four interdisciplinary activities facilitated by the pediatric palliative care team. The Compassionate Care Network (CCN) provides an open forum for interdisciplinary networking and education. Palliative Care Rounds (PCR) provides education through monthly case-based discussions on selected units. Patient Care Conferences (PCC) facilitate communication and care planning for selected patients with palliative care needs on any unit in the children's center. Bereavement Debriefing Sessions (BDS) offer health professionals the opportunity to manage their responses to grief after a patient's death. EVALUATION MEASURES: From February 2002 to September 2003, we prospectively tracked the frequency of sessions conducted, the number and discipline of attendees, the age and diagnosis of patients discussed, and themes raised at each session. Participants evaluated each session.

RESULTS

One hundred one sessions were conducted (PCR = 31, PCC = 23, CCN = 9, BDS = 38) for 950 participants (PCR = 312, PCC = 188, CCN = 193, BDS = 257). All units and disciplines participated in one or more sessions. Evaluations report that sessions are informative and will influence future professional practice.

CONCLUSIONS

A program of interdisciplinary interventions can successfully educate and support health care professionals in providing palliative and end-of-life care for children. This program model can be applied in diverse pediatric health care settings.

Qualitative study of Chinese widows in Hong Kong: insights for psycho-social care in hospice settings

In an exploratory, phenomenological study of seven Chinese widows in Hong Kong, five major themes are identified: relationship with the deceased, relationship with others, grief reactions, coping and emotional expression. This paper focuses on the first theme: the widows' relationship with the deceased husband along a timeline from the time of diagnosis to after death. The experiences in the final days with the deceased were frequently referred to when the informants talked about this theme. This paper aims to give added voice, based on the experience of Chinese widows, to the possible role of hospice and palliative care on influencing the bereavement experience. Issues of awareness and acceptance of death, the supportive environment and support for family carers, the moment of death, creation of legacies, and sensitivity towards cultural embedded practices, are discussed. It is hoped that the experiences of these bereaved widows will stimulate new research to elucidate and verify the findings reported in this paper.