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

Critical Care Experience Shapes Respiratory Therapists' Attitudes toward Death: A Survey Study

Respiratory therapists (RTs) frequently encounter death in their work with critically ill patients. Healthcare providers' attitudes toward death significantly affect their approach to caring for dying patients; however, there is a lack of knowledge on RTs' attitudes toward death. This study examines how the work environment and personal characteristics of RTs influence their attitudes toward death. Utilizing the Death Attitude Profile-Revised-Chinese questionnaire, a cross-sectional survey compared non-critical care RTs (non-CCRTs, N = 86) to critical care RTs (CCRTs, N = 85). Non-CCRTs displayed significantly lower scores in overall acceptance of death compared to CCRTs (p = 0.015) and a tendency to actively avoid thoughts about death (p = 0.005). CCRTs scored higher in "neutral acceptance" (p = 0.015), and non-CCRTs exhibited higher scores on items reflecting a negative attitude toward death. RTs with shorter professional tenures showed heightened fear of death and avoidance tendencies. Perception of life and death education correlated with higher "fear of death" and "death avoidance" scores (p = 0.001). The findings indicate that CCRTs demonstrate a more neutral acceptance of death. Additionally, experience, sex, mental health status, and life-death education exposure significantly influence RTs' attitudes toward death.

Perception of Personal Participation of the Nurses in Resuscitation Procedures: A Qualitative Study

Background and Objectives: Resuscitation is one of the most stressful tasks in emergency medicine. The participation of nurses in this procedure can have specific effects on them. In this research, we wanted to find out what these effects are. Materials and Methods: A qualitative approach by conducting semi-structured interviews was used, and a thematic data analysis of the recorded interviews was carried out. The collected data were transcribed verbatim, with no corrections to the audio recordings. The computer program ATLAS.ti 22 was used for the qualitative data analysis. Results: Eleven male registered nurses were interviewed, with an average of 18.5 years of experience working in a prehospital environment (max. 32/min. 9). A total of 404 min of recordings were analyzed, and 789 codes were found, which were combined into 36 patterns and 11 themes. As the most stressful situations, the interviewees pointed out the resuscitation of a child, familiar persons, conflicts with the environment, conflicts within the resuscitation team, nonfunctioning or insufficient equipment, complications during resuscitation, and resuscitating a person only for training. As positive effects, the interviewees cited successful resuscitations or their awareness that, despite an unsuccessful resuscitation, they did everything they could. Conclusions: Participation in these interventions has a specific positive or negative impact on the performers. The interviewees shared the opinion that they can cope effectively with the adverse or stressful effects of resuscitation. Yet, despite everything, they allow the possibility of subconscious influences of this intervention on themselves.

"A Life Slips Through Our Fingers" Experiences of Nurses Working in Pediatric Intensive Care Units About Children's Death: A Qualitative Study

Caring for a dying child can be an experience full of all kinds of negative emotions, pain and stress for the pediatric nurse. In this study, which was carried out in Turkey, we aimed to determine how nurses working in a pediatric intensive care unit remembered and made sense of their experiences regarding children's deaths. In-depth interviews were held with 13 nurses. The data were analyzed using the content analysis method. Three themes were identified. These were (1) Personal effects of death, (2) Difficulties in care, and (3) Coping with death. It was clear that the nurses were traumatised by their exposure to infant deaths. The findings showed that nurses experienced regret, fatigue and posttraumatic stress disorder. In addition, it was determined that nurses should be supported to cope with child deaths, which is a complicated process involving the child and the family, especially emotionally. Moreover, providing institutional support to nurses and referring them to cognitive-behavioral therapies may make it easier for them to cope with the emotional burden they carry, as well as the burnout they experience.

Grief Support and Coping Mechanism Mediate the Effect of Grief on Burnout Among Intensive Care Unit Nurses: A Structural Equation Modeling Analysis

BACKGROUND

Patients' death caused the intensive care unit (ICU) nurses to grieve, which led to their burnout. Intensive care unit nurses use various coping mechanisms and need support to overcome grief.

OBJECTIVE

The aim of this study was to identify the mediation effects of coping mechanisms and grief support on the impact of grief on burnout.

METHOD

This cross-sectional study among 660 ICU nurses from 9 hospitals used 4 self-reported instruments to collect data, apart from the sociodemographic and employment-related variables. A final model was developed through structural equation modeling after establishing the construct validities of the measures through confirmatory factor analysis.

RESULTS

The representation of ICU nurses from each hospital was greater than 50%, with the majority being female (90.8%) with a mean age of 27.27 years. Most nurses perceived the absence of grief, low burnout, and moderate to low grief support. The nurses use various coping mechanisms. Grief support significantly mediated the relationship between grief and burnout using a bootstrapping method with a mediation strength using the variance counted for (VAF) of 34.95%. The final model fit indices with acceptable values validated the direct and indirect relationships of grief, grief support, and coping mechanisms on burnout.

DISCUSSION

The significant influence of grief support in mediating the effect of grief on burnout is an important finding. The nursing and hospital management can use this finding to provide grief support to ICU nurses, enhance the grief support resources, and promote future studies to test the model's validity and applicability to health care professionals who frequently face patients' death.

"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.

Game-matching background music has an add-on effect for reducing emotionality of traumatic memories during reconsolidation intervention

INTRODUCTION

Hospital is a stressful place of employment, and a high proportion of healthcare workers, especially the ICU (Intensive Care Unit) nurses were found to be at risk of PTSD. Previous studies showed that taxing working memory through visuospatial tasks during the reconsolidation process of aversive memories can reduce the number of intrusions afterwards. However, the finds could not be replicated by some researches, indicating there may be some boundary conditions that are subtle and complex.

METHODS

We performed a randomized controlled trial (ChiCTR2200055921; URL: www.chictr.org.cn). In our study, a series of ICU nurses or probationers who performed a cardiopulmonary resuscitation (CPR) were enrolled and instructed to play a visuospatial music tapping game ("Ceaseless Music Note", CMN; Beijing Muyuan Technology Co., Ltd., Beijing, China) at the fourth day after CPR. The numbers of intrusions each day were recorded from the first to the seventh days (24 h×6 day), and the vividness and emotionality of CPR memories were rated at the 4th and 7th days. These parameters were compared between different groups (game with background sound; game with sound off; sound only; none).

RESULTS

The game-matching background music can have an add-on effect for single tapping game with no sound in reducing the emotionality of previous aversive memories.

DISCUSSION

We proposed that flow experience (the subjective experience of effortless attention, reduced self-awareness, and enjoyment, and may be induced by optimal skill-demands compatibility in challenging tasks) as a key boundary condition for successful reconsolidation intervention.

CLINICAL TRIAL REGISTRATION

www.chictr.org.cn, identifier: ChiCTR2200055921.

Worker Experiences of the Work Health and Safety Impacts of Exposure to Dying and Death in Clinical Settings: A Qualitative Scoping Review

Workers employed in clinical healthcare settings often encounter dying and death of patients as a part of their role. This scoping review aimed to explore the physical and psychosocial OHS impacts on health workers exposed to death within their occupational role and their inherent coping strategies. Six electronic databases PsycINFO (Ovid), Medline (Ovid), AMED (EBSCO), CINAHL (EBSCO), and Proquest Social Sciences were searched for peer reviewed research articles published between March 1971 and April 2022. PRISMA-ScR guidelines were followed. Three authors independently assessed articles for inclusion. Fifty-three studies with focus settings in hospitals, hospice, general practice and residential care were identified. Five main themes were developed and organized using and ergonomic systems approach: Cultural Environment, Workplace, Job Demands, Impacts and Coping. The findings demonstrate that caring for dying patients, the dead and their families in clinical settings impacts workers emotionally, physically, behaviorally and spiritually.

A qualitative study of phenomenology of perspectives of student nurses: experience of death in clinical practice

Aim

To describe the experiences of student nurses in confronting the death of their patients, and to understand how they cope with these events and to what extent there are unmet needs that can be addressed in their trainings.

Methods

Semi-structured interview method was used to collect data from Chinese nursing students and then Colaizzi’s seven-step analysis method was applied to identify recurrent themes in their responses to patient deaths. We listened the tape repeatedly combined with observations of their non-verbal behaviors, then transcribed them with emotional resonance, and entered them into Nvivo. After that, we extracted repeated and significant statements from the transcriptions, coded, then clustered codes into sub-themes and themes which were identified by the comparation with transcriptions and re-confirmation with our participants.

Results

After confirmation from the interviewees, five themes emerged: emotional experience, challenge, growth, coping and support.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-022-00846-w.

Nurses' involvement in end-of-life decisions in neonatal intensive care units

BACKGROUND

End-of-life decision-making for terminally ill neonates raises important legal and ethical issues. In Greece, no recent data on nurses' attitudes and involvement in end-of-life decisions are available.

RESEARCH QUESTION/AIM

To investigate neonatal nurses' attitudes and involvement in end-of-life decisions and the relation to their socio-demographic and work-related background data.

RESEARCH DESIGN

A survey was carried out in 28 neonatal intensive care units between September 2018 and January 2019. A structured questionnaire was distributed by post.

PARTICIPANTS AND RESEARCH CONTEXT

The questionnaire was answered anonymously by 312 nurses (response rate, 71.1%) and returned to the investigators.

ETHICAL CONSIDERATIONS

The study was approved by the Bioethics and Research Committee of Aretaieio Hospital in accordance with the Helsinki Declaration.

FINDINGS

Nurses more often reported involvement in various end-of-life decisions, such as continuation of treatment without adding further therapeutic interventions for terminally ill neonates, while less reported were mechanical ventilation withdrawal and drug administration to end life. Nurses with a high attitude score, reflecting a more quality-of-life approach, were more likely to be involved in setting limits to intensive care. α low score was consistent with life preservation. Nurses' religiousness (p = 0.097), parenthood (p = 0.093), involvement in daily practice (p = 0.03), and position on the existing legal framework (p < 0.002) influenced their attitude score.

DISCUSSION

The likelihood of nurses to support interventions in neonates with poor prognosis in neonatal intensive care units was related to their attitudes. After adjusting for potential confounders, the most important predictors for nurses' attitudes were parenthood, involvement in daily practice, and position supporting current legislation reform.

CONCLUSION

Variability in involvement in end-of-life decisions among nurses exists on a national level.

Exploring the Feelings of Nurses during Resuscitation—A Cross-Sectional Study

Cardiopulmonary resuscitation (CPR) is one of the most stressful situations in emergency medicine. Nurses involved in performing basic and advanced resuscitation procedures are therefore exposed to a certain amount of stress. The purpose of this study was to determine the stressors and the level of stress experienced by nurses during resuscitation. A cross-sectional quantitative study was done. The sample consisted of 457 nurses who worked in emergency units. First demographic data were collected, followed by a questionnaire regarding the effect of different situations that occur during and after resuscitation on nurses including Post-Code Stress Scale questionnaire. The most disturbing situations for respondents were resuscitation of young person (MV = 3.7, SD = 1.4), when they fail to establish an intravenous pathway (MV = 3.5, SD = 1.4), chaotic situation during resuscitation (MV = 3.4, SD = 1.4) and making decision about termination of resuscitation (MV = 3.1, SD = 1.5). Research has shown that nurses are exposed to a certain amount of stress during resuscitation, but most of them manage to compensate for stress effectively.

A genealogy of what nurses know about 'the good death': A socio-materialist perspective

In this article, we report the outcome of a sociological inquiry into nursing knowledge of death and dying, specifically 'the good death'. A genealogical approach informed by actor-network theory and appreciative inquiry were used to compose a broad socio-material account of how nurses concern themselves with the care of the dying and end-of-life care. Our enquiry revealed similarly to other studies, that there was no shared or overarching model of care. Key themes derived from nurses' translations of 'the good death' were re-presented pictorially as six pillars and two processes to comprise a new diagram of The Personalised Ideal Death.

Clinician distress in seriously ill patient care: A dimensional analysis

BACKGROUND

Caring for patients with serious illness may severely strain clinicians causing distress and probable poor patient outcomes. Unfortunately, clinician distress and its impact historically has received little attention.

RESEARCH PURPOSE

The purpose of this article was to investigate the nature of clinician distress.

RESEARCH DESIGN

Qualitative inductive dimensional analysis.

PARTICIPANTS AND RESEARCH CONTEXT

After review of 577 articles from health sciences databases, a total of 33 articles were eligible for analysis.

ETHICAL CONSIDERATIONS

This study did not require ethical review and the authors adhered to appropriate academic standards in their analysis.

FINDINGS

A narrative of clinician distress in the hospital clinician in the United States emerged from the analysis. This included clinicians' perceptions and sense of should or the feeling that something is awry in the clinical situation. The explanatory matrix consequence of clinician distress occurred under conditions including: the recognition of conflict, the recognition of emotion, or the recognition of a mismatch; followed by a process of an inability to feel and act according to one's values due to a precipitating event.

DISCUSSION

This study adds three unique contributions to the concept of clinician distress by (1) including the emotional aspects of caring for seriously ill patients, (2) providing a new framework for understanding clinician distress within the clinician's own perceptions, and (3) looking at action outside of a purely moral lens by dimensionalizing data, thereby pulling apart what has been socially constructed.

CONCLUSION

For clinicians, learning to recognize one's perceptions and emotional reactions is the first step in mitigating distress. There is a critical need to understand the full scope of clinician distress and its impact on the quality of patient-centered care in serious illness.

Critical Care Nurses’ Experiences of End-of-Life Care: A Qualitative Study

Background: Patients admitted to the intensive care unit (ICU) may face terminal illness situations, which may lead to death. In this case, the role of critical care nurses shifts from life-sustaining to end-of-life care (EOLC). Nurses’ involvement in EOLC varies between countries, even in one country due to differences in religion, culture, organization, laws, cases and patient quality. In Indonesia, research on EOLC in ICU has not been carried out.Purpose: This study aimed to explore the experiences of critical care nurses in providing EOLC.Methods: A qualitative study with a phenomenological approach was conducted. Ten critical care nurses having the experiences of caring for dying patients were recruited through a purposive sampling technique for in-depth interviews. Manual content analysis was used to identify themes.Results: The results of the study found five themes, including the challenge of communication with the family, support for the family, support for the patient, discussion and decision making, and nurses’ emotions. Conclusion: Most of EOLC provided by critical care nurses was focused on the family. They had some challenges in communication and decision making. Nurses need to get training and education about how to care for patients towards the end of life.

Nurse-facilitated reflective exercise post patient death in the ICU: a best practice implementation project

INTRODUCTION

ICUs are stressful environments where patient care is complex and demanding; death is not an unusual outcome. Nurses can become emotionally distressed from experiencing multiple, unexpected, or traumatic patient deaths. Performing a reflective exercise immediately post death is one coping strategy which encourages healthcare staff and family to debrief their feelings in a timelier manner.

OBJECTIVES

The aim of this project was to educate the nurses in the ICU with emotional coping skills pertaining to the effects of patient deaths. The objective was to implement a nurse-guided reflective exercise following each patient death in three adult ICUs in a quaternary academic medical center.

METHODS

The current change project used the Joanna Briggs Institute's Getting Research into Practice and Practical Application of Clinical Evidence Systems for auditing and strategy development. After standardizing the reflective exercise procedure, teaching methods were employed to support implementation. One follow-up audit measured compliance with completing a reflective exercise for all deaths occurring in the three ICUs. Contextual data were collected for completed exercises including type of death and words to describe nurses' emotions.

RESULTS

The reflective exercise script was revised and the standard procedure posted to the intranet for easy access. All ICU nurses received education on the use of this reflective exercise. For each of the two ICUs where this practice was new, compliance with nurses initiating and completing a reflective exercise was at a rate of 17 and 2%, respectively. For the ICU where reflective exercise was reintroduced, compliance was 30%. All deaths included in this study were anticipated (e.g., patient on comfort care) and calm, with the exception of one post cardiac arrest death.

CONCLUSION

Despite multipronged teaching for why, when, and how to use reflective exercise, there was minimal success in completing reflective exercises in the two units where the practice was new. This outcome was most likely due to higher than anticipated levels of needed support or the unpredictability of frequency of deaths on each unit. However, the main achievement was having the Minute of Silence procedure with a standardized script readily available at all times for nursing staff. Reimplementation success in the other ICU was attributed to more recently established reflective practices. Further exploration of barriers, such as type of death, and re-education are essential strategies to bolster and sustain practice and to provide support for our nursing staff to prevent emotional distress.

Work environment factors in coping with patient death among Spanish nurses: a cross-sectional survey

Objective:

to explore self-perception competence among Spanish nurses dealing with patient death and its relationship with work environment, evidence-based practice, and occupational stress.

Method:

a cross-sectional web-based survey collected information from a convenience sample of 534 nurses from professional Spanish Colleges who answered four validated questionnaires: Coping with Death Scale, Practice Environment Scale of the Nursing Work Index, Perception of Evidence-Based Practice (EBP) and Nursing Stress Scale.

Results:

a total of 79% of the participants were women, the average age was 40 years old, 38% had a postgraduate degree and 77% worked in public health settings. Many nurses evaluated their work environment as unfavorable (66%), reported high occupational stress (83.5±14.9), and had high scores on knowledge/skills in EBP (47.9±11.3). However, 61.2% of them perceived an optimal coping (>157 score). The multivariate logistic model indicated positive associations with work environment and EBP characteristics (OR: 1.30, p=0.054; OR: 1.04, p=0.007; OR: 1.13, p<0.001, respectively) but negative associations with occupational stress and short work experience (OR: 0.98, p=0.0043; OR: 0.74, p<0.002, respectively). These factors explained 23.1% of the coping variance (p<0.001).

Conclusion:

although most nurses perceived optimal coping, the situation could be enhanced by modifying several contextual factors. The identification of these factors would improve the quality of end-of-life care by facilitating nursing management.

[Person-Centered Relational Care Experienced by Critical Care Nurses: An Interpretative Phenomenological Analysis Study]

PURPOSE

The aim of the study was to explore nurses' experience of person-centered relational care in the context of critical care.

METHODS

Key interview questions were developed based on the human-to-human relationship model suggested by Travelbee. Data were collected through in-depth interviews with a purposive sample of 11 nurses having more than 2 years of working experience in intensive care units. An interpretative phenomenological analysis was conducted to analyze the data.

RESULTS

Four super-ordinate and nine sub-ordinate themes were identified. Emerged super-ordinate themes were as follows: (1) encountering a live person via patient monitoring systems; (2) deep empathic connection; (3) humanistic and compassionate care, and (4) accompanying the journey to the end. Study findings revealed that nurses in intensive care units experienced 'balancing emotions' and 'authenticity' in caring when entering human-to-human relationships with dying patients. The phenomenon of person-centered relational care in intensive care units was found to subsume intrinsic attributes of empathy, compassion, and trust, similar to the central concepts of Travelbee's theory.

CONCLUSION

The interpretative findings in this study provide deeper understanding of Travelbee's human-to-human relationship model. The technological environment in intensive care units did not hinder experienced nurses from forming human-to-human relationships. These themes need to be emphasized in critical care nursing education as well as in nursing management. The results of this study will contribute to understanding nurse-patient caring relationships in depth, and help improve the quality of nursing care in intensive care units.

[Feminization of the patient in thoracic oncology and experiences of caregivers: An exploratory study]

INTRODUCTION

The epidemiology of lung cancer is evolving and caregivers need to address an emerging demographic, women, sometimes presenting at a young age. The effect of this ongoing change on thoracic oncology services and on the nursing population (registered nurses and auxiliary nurses) has not been evaluated.

METHODS

A quantitative analysis can help to control the biases that may have an impact on nursing staff identification with female patients. A categorical and automated qualitative study (Tropes software) of speech productions related to "difficult situations" was carried out.

RESULTS

Four contexts activating critical situations were identified: disagreement and conflict in care, a constraining situation of care, an overflow situation, particularly related to increased suffering of the patient and a feeling of being isolated in care delivery. Regarding the management of female patients, after the impact of disagreements in management, the feeling of care being constrained in the presence of a female patient with whom caregivers identify themselves is more significant than with regard to male patients.

CONCLUSION

Support within the care team is essential, but not sufficient. Only a practice-based training context involving peers outside the team seems to help address the most impactful situations.

Stress and Coping of Critical Care Nurses After Unsuccessful Cardiopulmonary Resuscitation

BACKGROUND

Participation by a critical care nurse in an unsuccessful resuscitation can create a unique heightened level of psychological stress referred to as postcode stress, activation of coping behaviors, and symptoms of posttraumatic stress disorder (PTSD).

OBJECTIVES

To explore the relationships among postcode stress, coping behaviors, and PTSD symptom severity in critical care nurses after experiencing unsuccessful cardiopulmonary resuscitations and to see whether institutional support attenuates these repeated psychological traumas.

METHODS

A national sample of 490 critical care nurses was recruited from the American Association of Critical-Care Nurses' eNewsline and social media. Participants completed the Post-Code Stress Scale, the Brief COPE (abbreviated), and the Impact of Event Scale-Revised, which were administered through an online survey.

RESULTS

Postcode stress and PTSD symptom severity were weakly associated (r = 0.20, P = .01). No significant associations between coping behaviors and postcode stress were found. Four coping behaviors (denial, self-distraction, self-blame, and behavioral disengagement) were significant predictors of PTSD symptom severity. Severity of postcode stress and PTSD symptoms varied with the availability of institutional support.

CONCLUSIONS

Critical care nurses show moderate levels of postcode stress and PTSD symptoms when asked to recall an unsuccessful resuscitation and the coping behaviors used. Identifying the critical care nurses most at risk for PTSD will inform the development of interventional research to promote critical care nurses' psychological well-being and reduce their attrition from the profession.

Supporting families of dying patients in the intensive care units

Family support in the intensive care units is a challenge for nurses who take care of dying patients. This article aimed to determine the Iranian nurses' experience of supporting families in end-of-life care. Using grounded theory methodology, 23 critical care nurses were interviewed. The theme of family support was extracted and divided into 5 categories: death with dignity; facilitate visitation; value orientation; preparing; and distress. With implementation of family support approaches, family-centered care plans will be realized in the standard framework.

Bedside nurse involvement in end-of-life decision making: a brief review of the literature

Bedside nurses in the critical care setting deal with death on a regular basis. Historically, end-of-life decision making has been addressed by physicians with the family and patient, yet nurses may be a better resource for families during the decision-making process. The purpose of this article was to provide a brief review of literature surrounding end-of-life decision making. As patient advocates, nurses should be more actively involved with facilitating the end-of-life decision-making process for critically ill patients and their families.