How do nurses deal with their own grief when a patient dies on an intensive care unit, and what help can be given to enable them to overcome their grief effectively?

"Time and life is fragile": An integrative review of nurses' experiences after patient death in adult critical care

INTRODUCTION

Providing bereavement support and care to families is an aspect of critical care nursing practice that can be rewarding, yet emotionally and psychologically challenging. Whilst significant research has focused on end-of-life care in critical care, less is known about nurses' experiences after patient death.

AIM

The aim of this study was to synthesise research evidence on the experience of registered nurses after patient death in adult critical care.

DESIGN

A structured integrative review of the empirical literature was undertaken. A combination of keywords, synonyms, and Medical Subject Headings were used across the Cumulative Index Nursing and Allied Health Literature (CINAHL) Complete, Ovid Medline, PsycInfo, Embase, and Emcare databases. Records were independently assessed against inclusion and exclusion criteria. A process of forward and backward chaining was used to identify additional papers. All papers were assessed for quality. Narrative synthesis was used to analyse and present the findings.

RESULTS

From the 4643 records eligible for screening, 36 papers reporting 35 studies were included in this review, representing the voices of 1687 nurses from more than 20 countries. Narrative synthesis revealed three themes: (i) postmortem care, which encompassed demonstrating respect and dignity for the deceased, preparation of the deceased, and the concurrent death rituals performed by nurses; (ii) critical care nurses' support of bereaved families, including families of potential organ donors and the system pressures that impeded family support; and (iii) nurses' emotional response to patient death including coping mechanisms.

CONCLUSIONS

Whilst a focus on the provision of high-quality end-of-life care should always remain a priority in critical care nursing, recognising the importance of after-death care for the patient, family and self is equally important. Acknowledging their experience, access to formal education and experiential learning and formal and informal supports to aid self-care are imperative.

"You gotta have your cry": Administrator and direct care worker experiences of death in assisted living

Assisted living (AL) is increasingly a site of end-of-life care and a long-term care location where growing numbers of people are aging in place and dying. Despite these trends, limited research focuses on how death and grief impact the work environment in AL. This grounded theory analysis examined qualitative data collected from 27 administrators and 38 direct care workers (DCWs) in 7 diverse settings. As assisted living administrators and DCWs experienced resident death, they engaged in a dynamic and individualized process of "managing the normalization of death," which refers to the balance of self-identity and workplace identity. The process of reconciling these opposing contexts in AL involved several individual- and community-level conditions. Administrators and DCWs would benefit from additional resources and training around death. Increasing collaboration with hospice and clarifying policies about death communication would better prepare the workforce to acknowledge the end of life in assisted living.

Evaluating a multidimensional strategy to improve the professional self-care of occupational therapists working with people with life limiting illness

BACKGROUND

The term 'life limiting conditions' refers to premature death following decline from chronic conditions, which is a common circumstance in which occupational therapists work with people at the end of life. The challenges for clinicians of working with these patients have long been recognised, and may have a significant impact on their professional self-care. This study aimed to evaluate a multidimensional workplace strategy to improve the professional self-care of occupational therapists working with people living with a life limiting condition.

METHODS

A pre and post mixed methods survey approach were utilised, with baseline data collection prior to the implementation of a multidimensional workplace strategy. The strategy included professional resilience education, targeted supervision prompts, changes to departmental culture and the promotion of self-care services across multiple organisational levels. Follow up data collection was undertaken after the strategy had been in place for 2 years. Quantitative data were analysed descriptively, while qualitative data were subjected to thematic analysis.

RESULTS

One hundred three occupational therapists responded (n = 55 pre, n = 48 post) across multiple service settings. Complex emotional responses and lived experiences were identified by participants working with patients with life limiting conditions, which were not influenced by the workplace strategy. Working with these patients was acknowledged to challenge the traditional focus of occupational therapy on rehabilitation and recovery. Participants were confident about their ability to access self-care support, and supervision emerged as a key medium. While the strategy increased the proportion of occupational therapists undertaking targeted training, around half identified ongoing unmet need around professional self-care with this patient group. Demographic factors (e.g. practice setting, years of experience) also had a significant impact on the experience and needs of participants.

CONCLUSIONS

The multidimensional workplace strategy resulted in some improvements in professional self-care for occupational therapists, particularly around their use of supervision and awareness of available support resources. However, it did not impact upon their lived experience of working with people with life limiting conditions, and there remain significant gaps in our knowledge of support strategies for self-care of occupational therapist working with this patient group.

“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.

Experiences of Canadian oncologists with difficult patient deaths and coping strategies used

OBJECTIVES

We aimed to explore and identify what makes patient death more emotionally difficult for oncologists and how oncologists cope with patient death.

METHODS

A convenience sample of 98 Canadian oncologists (50 men, 48 women) completed an online survey that included a demographics section and a section about patient death.

RESULTS

More than 80% of oncologists reported that patient age, long-term management of a patient, and unexpected disease outcomes contributed to difficult patient loss. Other factors included the doctor-patient relationship, identification with the patient, caregiver-related factors, oncologist-related factors, and "bad deaths." Oncologists reported varying strategies to cope with patient death. Most prevalent was peer support from colleagues, including nurses and other oncologists. Additional strategies included social support, exercise and meditation, faith, vacations, and use of alcohol and medications.

CONCLUSIONS

Oncologists listed a number of interpersonal and structural factors that make patient death challenging for them to cope with. Oncologists reported a number of coping strategies in responding to patient death, including peer support, particularly from nursing colleagues. No single intervention will be suitable for all oncologists, and institutions wishing to help their staff cope with the emotional difficulty of patient loss should offer a variety of interventions to maximize the likelihood of oncologist participation.

Oncologists' negative attitudes towards expressing emotion over patient death and burnout

PURPOSE

The aims of this study were to examine the relationship between negative attitudes towards expressing emotion following patient death and burnout in oncologists and to explore oncologists' preferences for institutional interventions to deal with patient death.

METHODS

The participants included a convenience sample of 177 oncologists from Israel and Canada. Oncologists completed a questionnaire package that included a sociodemographic survey, a burnout measure, a survey assessing negative attitudes towards expressing emotion, and a survey assessing desired interventions to cope with patient death. To examine the association between burnout and negative attitudes while controlling for the effect of sociodemographic variables, a hierarchical linear regression was computed.

RESULTS

Higher burnout scores were related to higher negative attitudes towards perceived expressed emotion (partial r = .25, p < .01) of those who viewed this affect as a weakness and as a sign of unprofessionalism. Approximately half of the oncologists found each of the five categories of institutional interventions (pedagogical strategies, emotional support, group/peer support, taking time off, and research and training) helpful in coping with patient death.

CONCLUSIONS

Our findings suggest that high burnout scores are associated with negative attitudes towards expressing emotion and that there is a wide variation in oncologist preferences in coping with patient death. Institutions should promote interventions that are varied and that focus on the needs of oncologists in order to reduce burnout. Interventions that legitimize expression of emotion about patient death may be useful. Another way to reduce stigma would be to require oncologists to "opt out" rather than "opt in" to accessing a selection of social and/or individual interventions.

Taking care of care providers: a wellness program for pediatric nurses

The cumulative effect of professional stress and compassion fatigue within the health care profession has been receiving increasing attention. The impact can be especially worrisome for nurses who work with chronic illness populations, such as oncology. While interventions targeted at reducing nurses stress and promoting wellness are cited as necessary, they are often lacking in busy medical environments. In this article, the authors describe a newly developed 10-session wellness program that was offered on 2 occasions to both inpatient and outpatient nursing staff. The nursing staff chose the content areas, and each session used a combined approach of hands on and didactic learning. A description of the activity offered during each session along with the core competency and objectives measured are provided. Overall, staff found the wellness series very helpful to themselves and to their ability to positively change their job performance.

What do oncologists want? Suggestions from oncologists on how their institutions can support them in dealing with patient loss

PURPOSE

The purpose of the study was to explore what institutional support(s) oncologists want to help them cope with patient loss.

METHODS

The grounded theory method was used. Twenty oncologists were recruited and interviewed between November 2010 and July 2011 from three adult oncology centers in Ontario. Data collection and analysis took place concurrently. Analysis involved line-by-line coding, and was inductive, with codes and categories emerging from participants' narratives.

RESULTS

Oncologists suggested institutional supports that fit under four categories that included: (1) training, information and education including fellowship training, grand rounds and the availability of fact sheets; (2) acknowledgment and validation of grief including normalizing grief, having forums to share experiences, supportive mentorship and group debriefing sessions; (3) institutional psychosocial support including access to professional help and the nursing care model; and (4) vacations and sabbaticals.

CONCLUSIONS

Institutions such as medical schools and hospitals have both the opportunity and the obligation to support oncologists with this difficult aspect of their work. In addition to offering ongoing education and forums to share experiences, medical institutions can also provide supportive mentorship models to junior oncologists on how to cope with patient loss.

Greek renal nurses' attitudes towards death

This study aims to assess how Greek renal nurses feel about death and examine any relationships between their attitudes and demographic factors.

DESIGN

Descriptive quantitative study. The sample comprised of 49 nurses.

METHODOLOGY

Voluntary and anonymous completion of the Death Attitude Profile-Revised and a demographic questionnaire.

RESULTS

44 respondents were female and 5 were male with a mean age of 25.80 years. The mean nursing experience was 10.9 years. Nursing experience and age were the variables most likely to predict nurses' attitudes towards death. Nurses with specific education on palliative care had less difficulty talking about death and dying and did not have a fear of death. The Hospital-based teams (known as palliative care teams, supportive care teams or symptom assessment teams) had statistically significant different relationships with fear of death and neutral acceptance scores.

CONCLUSIONS

It is recommended to include education on death and care of the dying in the nursing degree course in order for nurses who are giving terminal phase patient care to be better able deal with issues that death evolves.

[Cultural strategies for coping with infant death in a Pediatric Intensive Care Unit]

OBJECTIVES

To analyze what is the conceptualization the nurses have of child death in a Pediatric Intensive Care Unit (PICU) and identify sociocultural strategies for coping with it.

METHODOLOGY

DESIGN

qualitative methodology. Etnography.

STUDY SITE

PICU University Hospital Gregorio Marañón. Madrid.

STUDY SUBJECTS

nurses and nursing assistants who work in the PICU.

DATA COLLECTION

Observation participant and semi-structured in-depth interview. Organization and analysis of the data: the analytic procedure posed from the Established Theory. SOFTWARE OF SUPPORT: Atlas-ti.

RESULTS

Child death acquires specific meanings in the PICU context. Cognitive classifications and symbols give meaning to a reality to which the nursing professionals adapt through the creation of cultural coping strategies. Based on the data, 5 strategies could be identified: redefinition of the death concept, delay in identity assignment of the children, <<arrangement>> (funeral rituals), discharge metaphor, and avoidable condensed symbols.

CONCLUSIONS

Hidden behind the indifferent aspects of our daily life, difficult social and cultural constructs support our living and working efforts. Through daily life Anthropology we can know and understand our relationship with all our surroundings. When we are aware of them, we can develop new resources and strategies to adapt to the difficult circumstances they cause, in this case, within the context of critical ill child care.

A descriptive study of coping strategies used by Medical Intensive Care Unit nurses during transitions from cure- to comfort-oriented care

OBJECTIVE

The aim of this study was to describe Medical Intensive Care Unit (MICU) nurses' coping behaviors while caring for a patient whose medical treatment transitioned from cure- to comfort-oriented care.

METHODS

The use of a descriptive qualitative research design with brief selective participant observation and focus group interviews was used to explore the coping experiences of MICU nurses. The study took place in an 18-bed MICU that was part of a 719-bed acute care hospital located in the northeastern United States. Nineteen female and 5 male nurses participated in the study.

RESULTS

MICU nurses used a variety of coping strategies including cognitive, affective, and behavioral techniques to cope with end-of-life care transitions. Being a MICU nurse in and of itself provided a sense of pride for staff. Most believed that their clinical opinions were valued and that they were respected as professionals. Providing futile care, the perception of "torturing the patient," and conflict with families caused the greatest distress to staff.

CONCLUSIONS

MICU nurses are dynamic and resourceful when responding to challenging end-of-life patient care situations.

Critical Care Nurses’ Perceptions of Futile Care and Its Effect on Burnout

• Background Nurses’ perceptions of futile care may lead to emotional exhaustion.

• Objectives To determine the relationship between critical care nurses’ perceptions of futile care and its effect on burnout.

• Methods A descriptive survey design was used with 60 critical care nurses who worked full-time and had a minimum of 1 year of critical care experience at the 2 participating hospitals (350–470 beds). Subjects completed a survey on demographics, the Moral Distress Scale, and the Maslach Burnout Inventory. Six research questions were tested. The results of the following question are presented: Is there a relationship between frequency of moral distress situations involving futile care and emotional exhaustion?

• Results A Pearson product moment correlational analysis indicated a significant positive correlation between the score on the emotional exhaustion subscale of the Maslach Burnout Inventory and the score on the frequency subscale of the Moral Distress Scale. Moral distress accounted for 10% of the variance in emotional exhaustion. Demographic variables of age, education, religion, and rotation between the critical care units were significantly related to the major variables.

• Conclusions In critical care nurses, the frequency of moral distress situations that are perceived as futile or nonbeneficial to their patients has a significant relationship to the experience of emotional exhaustion, a main component of burnout.

Death, dying, and the ICU nurse

Death is a natural progression from life. Most nurses will be exposed to the physical and emotional effects of this experience as they care for a dying patient. The nurse is taught how to provide support for the patient and family as they proceed through the stages of grief. Often, however the nurse may not realize his or her own need to grieve.

Emotional support for dying patients--the nurses' perspective

This study describes and explains the provision of emotional support to the dying patients from the nurses' viewpoint. The results are part of a questionnaire survey concerned with terminal care on inpatient wards at community health centres in Finland. The sample consisted of 328 nurses from 32 health centres. The data were collected using a structured questionnaire in which emotional support was measured by multiple-choice items and one open-ended question. The data were analysed using content analysis. Listening, touching, expressing empathy, attending to the patients' wishes, comforting, encouraging and being present were the most common forms of emotional support. The support was mainly provided in connection with basic care. Problems concerning the provision of emotional support were focused on organisational resources, nursing staff, patients and family members. The size of the health centre, further training in the care of terminal patients and reading the literature were associated with the provision of support. In conclusion, nurses feel they need time as well as sufficient skills and competencies so that they can provide emotional support to the extent and in the way that they themselves want to.

A bereavement after-care service for intensive care relatives and staff: the story so far

The Intensive Care Society (1998) developed Guidelines for Bereavement Care in Intensive Care Units. In response to the guidelines, a group of nurses from the intensive care units at Glenfield Hospital in Leicester have developed a bereavement after-care service for relatives and staff. So far, the service has evaluated well from the feedback received from both relatives and staff, but evaluation is ongoing and the service is being continually developed.

How do nurses deal with their emotions on a burn unit? Hermeneutic inquiry

Burn unit nurses work in an emotionally exhausting environment and are frequently exposed to emotional trauma. Emotion is a difficult concept to define. This study used a hermeneutic-phenomenological approach to establish the experiences of nurses working on a burn unit to find out how they deal with their emotions. The findings suggest that nurses have little or no time to deal with their emotional experiences. This study has shown that current support services might be ineffective. Nurses realize that they have emotions. They also recognize the need to address these emotions. Recommendations for nursing practice are made as a result of these findings.

[The process of socialization of nurses at an intensive care center]

The objective of this study was to understand the process of socialization of the new professionals that are part of the subculture of an intensive care unit (ICU). Considering that the ICU is a subculture of the hospital, and that the professionals share symbols and meanings that were developed through social interactions in the context of Intensive Care the symbolic interacionism and the ethnographic description were used as a theoretical and methodological basis for this study. The participant observation, the ethnographic interview and the documented analysis were used to understand the process of internalization of the symbolic universe of the ICU. The results showed that in the socialization process quality values, discipline, commitment, sense of unit, rules and organizational values were reproduced. This process is permeated with feelings of insecurity, anxiety, distress, incompetence and fear. The causes for these feelings have a strong component in the previous nonexistence and in the gap of professional career. This process occurs in a formal and informal way but is always referred as difficult, lonely and sometimes shared.

Caring for dying infants: experiences of neonatal intensive care nurses in Hong Kong

Ten registered nurses working in a neonatal intensive care unit in Hong Kong were interviewed to explore their experiences of caring for infants whose disease is not responsive to curative treatment, their perceptions of palliative care, and factors influencing their care. Eight categories emerged from the content analysis of the interviews: disbelieving; feeling ambivalent and helpless; protecting emotional self; providing optimal physical care to the infant; providing emotional support to the family; expressing empathy; lack of knowledge and counselling skills; and conflicting values in care. The subtle cultural upbringing and socialization in nurse training and workplace environment also contributed to their moral distress. Hospital and nurse administrators should consider different ways of facilitating palliative care in their acute care settings. For example, by culture-specific death education, peer support groups, bereavement teams, modification of departmental policies, and a supportive work environment. Future research could include the identification of family needs and coping as well as ethical decision-making among nurses.

Nurses' responses to death and dying: a need for relentless self-care

This article examines the lived experiences of nurses responsible for administering care to dying patients. To achieve this, the article explores the notion of 'relentless self-care' and why this is an important feature of palliative nursing practice (Renzenbrink, 1998), even though for many nurses, their feelings of loss must remain hidden (Doka, 1989). Because of this, nurses try to protect themselves from distressing symptoms by distancing themselves from death. Consequently, nurses may locate dying patients in side-rooms and hand over part of their caring role to relatives (Sudnow, 1967; Wakefield, 1996, 1999). In view of these responses, the final part of the article will attempt to offer a way forward for the nursing profession, by examining why nurses should treat their own feelings of loss as being analogous to those of a bereaved relative.

Cancer patients', family members' and professional helpers' conceptions and beliefs concerning death

The purpose of this study was to examine the attitudes of different groups of people towards death, as well as their opinions and beliefs concerning life after death. The study is part of a larger research project in which cancer patients' suffering and coping were under examination. Data were collected in semi-structured focused interviews with 32 patients with incurable cancer, 13 family members, 13 nurses and 13 doctors from two central hospitals and four community health centres. The interviews were tape-recorded and transcribed verbatim. Data were analysed by content analysis. Most of the interviewees were not afraid of death. The professionals were slightly more often afraid of death than the patients and the family members. The participants gave many reasons for their opinions. The interviewees were not very interested in reading death-related literature. Only nurses had read a great deal of literature on death. Most of the participants believed in the existence of God and in life after death. The participants had different kinds of conceptions of the events after death. The doctors differed from the other groups in that they read less literature on death and had less faith in God and in life after death.

Grief support for nursing staff in the ICU

Patient death is a stressful experience for the patient, family, and the healthcare team. Nurses-often have only informal resources for coping with the sadness and grief they might experience. Realizing the need for nursing grief support, a group of staff nurses from the intensive care unit formed a grief support group. Using information from the literature and critical incident stress debriefing, the group developed support interventions to aid intensive care unit staff after patient death.

Care of the suddenly bereaved in cardiac care units: a review of the literature

This paper considers the experiences emerging from relatives whose loved ones die suddenly in a Cardiac Care Unit (CCU). It examines how best to address their needs and how to facilitate the normal grieving process during their brief yet traumatic hospital encounter. There appears to be no primary research relating specifically to sudden bereavement in a CCU. Several authors assume that findings can be applied between specialties but there is no empirical evidence to support this assumption. The research which does exist is predominantly in the areas of bereavement generally and in Accident and Emergency (A&E) in particular. This paper contains a critical examination of this literature and consideration of the extent to which findings from these fields can be relied upon to lead practice in the CCUs. It is concluded that recommendations for practice arising from such literature, e.g. those supporting the allocation of an advocate nurse to accompany relatives and allowing observation of resuscitation, may not be readily applicable to CCUs. The paper concludes with a consideration of future cardio-specific research needs.

Managing the stress of caring in ITU: a reflective practice group

Working in a busy intensive therapy unit can be psychologically demanding. A reflective practice group was set up to provide staff with a forum for discussion and support in an effort to manage the stress of caring in such an environment. There was no planned agenda and staff were encouraged to speak freely about both the rewarding and exacting aspects of the job. The weekly sessions were facilitated by staff from outside and unit. Their approach encouraged staff to develop and share their insights and experiences and helped to generate new ways of coping with the personal, interpersonal and professional demands of their work.

Pediatric intensive care nurses and their grief experiences: a phenomenological study

OBJECTIVE

To describe the grief experience of pediatric intensive care nurses when their patients die.

DESIGN

Heideggerian phenomenological approach; nonprobability, purposive sampling; semistructured interviews; data analyzed using Colaizzi's method of phenomenology.

SETTING

Pediatric intensive care unit within a Canadian pediatric metropolitan university teaching hospital.

PARTICIPANTS

Six registered nurses, currently working in the pediatric intensive care unit, who had experienced the death of at least three children for whom they had cared. Nursing experience ranged from 2 to 20 years, intensive care nursing experience from 9 months to 19 years, and tenure on the unit from 9 months to 15 years.

RESULTS

Data were analyzed for recurring themes according to the procedure outlined by Colaizzi. These nurses acknowledged they suffered multiple exposures to children's death and experienced grief. The interviews revealed eight themes that included one about their grief responses--hurting; two that described the influencing contextual factors--nurse-family unit relationship and dissonance; and five that related to coping strategies used to manage their feeling of grief--self-expression, self-nurturance, termination of relationship activities, engaging in control-taking activities, and self-reflection. Further analysis revealed that managing grief effectively was an experiential learning process for the participants.

CONCLUSIONS

These results demonstrate that pediatric intensive care nurses' grief is different from that of surviving family member grief. Further research is required to document in further depth the experiential learning process to coping with multiple, accumulated losses for these professional caregivers. The findings of this study also could encourage further research that examines interventions designed to enhance the type of education and support needed in relation to the grief experience of nurses.

Research in intensive care nursing

The results of a questionnaire study about intensive care nursing in Finland indicate that the chief problems in intensive care nursing are concerned with staff coping resources, quality development and patient experiences. Questions on staff stress and coping have been researched quite extensively. Earlier studies have described intensive care nursing as highly stressful and pointed to numerous problems related to coping. It is clear that intensive care nursing warrants closer attention in research.

Critical care nurses' lived experience of unsuccessful resuscitation

Although approximately 58% of patients in critical care units die despite resuscitation efforts, the experience of nurses who participate in unsuccessful patient resuscitation has been largely unexamined. The article is a description of a phenomenological research study designed to investigate this experience. Nine nurses employed in cardiac or intensive care units of a tertiary care hospital participated in the study by contributing paradigm narratives concerning unsuccessful patient resuscitation. The lived experience of unsuccessful resuscitation was described by the participants as one in which they fortified themselves for the emotional consequences and sense of loss associated with this experience while establishing a connectedness with the patient and his/her significant others.

Patient death in a long-term care hospital. A study of the effect on nursing staff

1. The most common ways in which staff were affected by patient death were "low morale" and "loss of efficacy at work." 2. Staff most commonly reported coping with death by "sharing feelings," knowing that their "work contributed to a good death" and by "placing death in a good light," although one in five nurses reported no strategy for dealing with patient death. 3. Nurses who are most affected by patient death have a more difficult time caring for younger patients, tend to "take their stress home" and are more likely to base their nursing care on a personal relationship with the patient, than nurses who are less affected.

Stressors experienced by nurses while caring for organ donors and their families

OBJECTIVES

To identify the stressors experienced by nurses who care for organ donors and their families.

DESIGN

Retrospective, exploratory, descriptive.

SETTING

Eastern Canada.

PARTICIPANTS

Seventeen nurses who worked in a neurologic intensive care unit were interviewed. All had provided care to organ donors.

RESULTS

The threat of the patient dying, the inconsistent commitment of physicians to organ donation, and returning to an empty space were frequently mentioned stressors. All nurses felt positive about being involved in the organ donation process.

CONCLUSION

To deal with the stressors, nurses recommended more education in the area of grief, crisis interventions, stress, and coping theories. More important, they suggested the need to address their feelings through stress debriefing sessions.