Supporting the Bereaved in the COVID-19 Era: A Scoping Review of Interventions

People whose family member(s) friend(s) have died from COVID-19 or other causes have been deeply affected by the physical and social restrictions imposed during the pandemic. These limitations have affected end-of-life care and support for the bereaved. The purpose of this review is to identify: the published studies of evaluated programs about interventions for people who have experienced bereavement during the COVID-19 pandemic, and to develop recommendations for researchers and policy makers. Using scoping review methodology, a literature review was undertaken for articles published from January 1, 2020 through February 28, 2023 to identify interventions shown to be beneficial to people who have experienced the death of loved ones during the COVID-19 pandemic. The search yielded 1588 articles of which three studies met the criteria of utilizing a pre and post-test design with only one of these, a randomized controlled trial. The interventions included in this review demonstrate preliminary efficacy.

Patterns and predictive value of acute prolonged grief and posttraumatic stress in youngsters confronted with traumatic loss: A latent class analysis

Deaths of relatives and peers in potentially traumatizing circumstances may lead to symptoms of prolonged grief (PG, e.g.,yearning, preoccupation) and posttraumatic stress (PTS, e.g., re-experiencing, hypervigilance). There is limited knowledge about how symptoms of PG and PTS co-occur following such events. The current study aimed to identify patterns of DSM-5-TR defined PG symptomatology and PTS in a sample of 213 youngsters, involved in a school bus accident killing seven peers 2 months earlier. Using latent class analysis, three groups were identified evidencing moderate endorsement of most symptoms (Class 1), high endorsement of almost all but the avoidance symptoms (Class 2), and high endorsement of almost all symptoms (Class 3), respectively. Classes differed in terms of levels of grief, PTS, and depression, assessed concurrently, and-in a subgroup of n=137 participants-assessed at 16 month follow-up. E.g., Class 3 membership was associated with a greater likelihood of meeting criteria for DSM-5-TR defined prolonged grief disorder at follow-up. Gender (fewer females in Class 1) but not age and proximity to the accident were associated with class membership. Findings indicate that it is important to identify groups with elevated PG and PTS early after traumatic bereavement who may be en route to persistent mental health problems.

International Standards for Pediatric Palliative Care: From IMPaCCT to GO-PPaCS

CONTEXT

Since the publication of the IMPaCCT project in 2007, much effort has been made to develop new approaches to pediatric palliative care (PPC). Fifteen years later, it is time to redefine the standards in PPC.

OBJECTIVES

An international group of experts in PPC has revised the standards in PPC through the GO-PPaCS project (Global Overview - PPC Standards). The goal was to update the PPC standards considering the specificity of different settings, resources, and emerging challenges. The present document is intended to reach all people directly or indirectly involved in PPC.

METHODS

A literature review in MEDLINE was conducted to expand on the fundamental points and current standards on PPC and to cover an international setting. The literature search (updated on the 15th of April 2021) was carried out using different combinations of keywords and focusing on papers published in English over the past 5 years (2016-2020), but older articles were considered when relevant. The consensus on the fundamental points, standards of care and paper contents was reached by open discussion.

RESULTS

Fundamental points were defined regarding the definition of PPC, eligibility criteria and the magnitude of the need for PPC, while standards were redefined for the following six areas: 1) clinical, developmental, psychological, social, ethical and spiritual needs; 2) end-of-life care; 3) care models and settings of care; 4) PPC in humanitarian emergencies; 5) care tools; and 6) education and training for healthcare providers.

CONCLUSION

The present document, developed with the contribution of an international group of experts from different countries, experiences and models of care, provides fundamental points and standards for a wider implementation of PPC worldwide.

Peer loss: Posttraumatic stress, depression, and grief symptoms in a traumatized adolescent community

In our prospective study, 168 adolescents exposed directly or indirectly to the same traumatic event-a fatal school bus accident-in which seven students were killed instantly, were assessed for post-traumatic stress, depression and grief symptoms at 2- and 18-months post-accident. Prevalence rates of likely PTSD and depression were noted across all types of physical proximity exposure: 77.6% and 48.1% respectively in the indirectly exposed group, 79.4% and 47.1% respectively in the directly in-the-area exposed group, and 77.8% and 42.1% respectively in the directly in-bus exposed group. One-fifth experienced high and unremitting levels of grief symptoms over time ("persistent grief"); 17% with initially high levels of grief symptoms showed a decrease at 18 months but were still within the low medium range ("towards recovery"); 39% with initially medium/high grief symptoms reported low levels of grief at the follow-up ("recovery"); and 23% of the participants experienced grief symptoms that remained persistently low ("resilient"). The absence of both PTSD and depression at 18 months predicted adjustment to loss, whereas the absence of depression at 18 months predicted a recovering course of grief. The findings highlight the impact of high levels of post-traumatic stress and depression symptoms on the long-term persistent grief outcome.

Home or hospital as the place of end-of-life care and death: A grounded theory study of parents' decision-making

BACKGROUND

While several studies have examined 'what' families want with regard to the place of a child's end-of-life care and death, few have explored 'how' parents reach a decision.

AIMS

(1) to develop a model explaining how parents of a child with a life-threatening illness in Greece decide about the place of end-of-life care and death; (2) to identify the factors affecting decision-making; (3) to consider the implications for clinical practice.

DESIGN

Grounded theory study of bereaved parents using semi-structured open-ended interviews following Strauss and Corbin's principles of data collection and analysis.

SETTING/PARTICIPANTS

Semi-structured interviews with 36 bereaved parents of 22 children who died at home (n = 9) or in a paediatric hospital (n = 13) in Athens, Greece.

RESULTS

(1) Decisions regarding place of care and death were reached in one of four ways: consensus, accommodation, imposition of professional decisions on parents or imposition of parents' decisions without including professionals. (2) Six factors were identified as affecting decisions: awareness of dying, perceived parental caregiving competence, perceived professional competence, parents' view of symptom management, timing of decision-making, and being a 'good parent'. (3) Decisions were clear-cut or shifting. Few parents did not engage in decisions.

CONCLUSION

Parents' decisions about place of end-of-life care and death are affected by personal, interpersonal, timing and disease-related factors. Parents are best supported in decision-making when information is presented clearly and honestly with recognition of what acting as 'good parents' means to them, and opportunities to enhance their caregiving competence to care for their child at home, if they choose so.

Psychometric Properties of the Revised Death Attitude Profile in a Greek Sample of Nurses

BACKGROUND AND PURPOSE

This study aimed to examine the psychometric properties of the Revised Death Attitude Profile (DAP-R) in a sample of Greek nurses and nursing students.

METHODS

A convenience sample (n = 934) was used from six National Health System hospitals, and two University Schools of Nursing in central and northern Greece completed the Greek version of the DAP-R (Gr-DAP-R).

RESULTS

Principal component analysis with varimax rotation revealed a six-factor solution, including approach acceptance, death avoidance, escape acceptance, neutral acceptance, fear of death, and after death concerns. The internal consistency for each of the subscales ranged from 0.64 to 0.88. Intercorrelations between the Gr-DAP-R subscales supported the relative independence of death attitudes dimensions.

CONCLUSIONS

The Gr-DAP-R can be used as a research and clinical tool in assessing death attitudes among Greek nurses.

Palliative care professional's perceptions of barriers and challenges to accessing children's hospice and palliative care services in South East London: A preliminary study

OBJECTIVES

Several barriers have been identified as preventing or delaying access to children's palliative care services. The aim of this study is to further explore such barriers from palliative care professionals' perspective from two London boroughs.

METHODS

Qualitative-five children's palliative care professionals' perceptions were obtained from semi-structured interviews.

RESULTS

Three themes emerged: availability and adequacy of child palliative care (e.g., unreliability of services), obstacles to accessing palliative care (e.g., logistical challenges), and cultural values and family priorities.

CONCLUSION

These findings contribute to the equal opportunities dialogue in this sector and the need for future research to address the challenges identified.

Addressing cultural issues in grief counseling with immigrants: The case of a bereaved Filipino family following homicide

This article discusses cultural considerations and approaches to working with bereaved immigrants who cope with traumatic loss. A clinical case is used to elaborate on issues related to cultural identity, level of acculturation as well as religious beliefs and rituals among Filipinos living in Greece. Considerations for clinicians, who provide services to culturally diverse families that experience traumatic deaths, are discussed.

Adolescents' trajectory through peer loss after a road traffic accident

This mixed method study investigated the short- and long-term effects of peer loss on eight adolescents after a fatal school bus accident. Phenomenological analysis of their retrospective narratives revealed three patterns (living in despair, collecting my pieces, remembering, and moving on). Quantitative findings indicate progressive decrease in post-traumatic stress symptoms severity across time; increase in positive changes in perceptions of self, others, and life between 18 and 34 months; and stable continuing bond with the deceased peers.

Challenges in Engaging Parents in the Drug and Alcohol Treatment: The Professionals' Perspective

Addiction treatment centers often fail to involve families in treatment. The aim of the present study was to explore the challenges that Greek mental health professionals encounter in their work with parents of drug and alcohol abusers. A qualitative study design was adopted, and five focus group discussions were conducted with 27 drug and alcohol professionals. The thematic analysis of their accounts revealed the key difficulties that professionals encounter in their collaboration with parents that included parental lack of involvement or over-engagement in treatment, unrealistic expectations, ambivalence or opposition to change, ethical dilemmas, and alliance issues, as well as collaboration challenges among therapists. Findings highlight the challenges of a family approach in the treatment of addiction, and underscore the value of clinical supervision in addition to specialized training, to help professionals work on their anxiety, anger, guilt, prejudices, and deception, when engaging parents in the treatment of their addicted child.

Caring for an intimate stranger: parenting a child with psychosis

WHAT IS KNOWN ON THE SUBJECT

The care of an adult son or daughter with psychosis is filled with overwhelming demands caused by the symptomatology and illness exacerbations. Parents display disenfranchised grief over multiple losses and report increased levels of emotional burden. Most studies use quantitative methods and rely on pre-existing theoretical frameworks to investigate, through psychometric measures, the effects of being a carer. Meaning attributions to the disorder, and changes in parent-child relations over time, are poorly understood.

WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE

This hermeneutic phenomenological study illuminates the subjective experience of parenting a son or daughter with psychosis, as it is lived and described by parents of young adults with psychosis. Findings suggest that the parents' perceptions of their child changes over the course of the disorder, leading to a redefinition of the parent-child relationship, causing alternations in attachment. Findings illuminate the parents' profound guilt over having contributed or not prevented the disorder, over not being 'good' parents and feeling ambivalent towards an 'intimate stranger.' Guilt is compensated by absolute dedication to the son or daughter's care, at the expense of their own well-being.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

Interventions for parents must be available as soon as possible, both during hospitalization and after discharge. Professionals should provide a therapeutic space, where parents could express intimate thoughts and feelings, address guilt, fear and resentment issues, be assisted in their parenting role as well as in the reconstruction of a sense of self and self-esteem. Professionals are invited to facilitate illness acceptance, provide accurate information, assist parents to redefine their relationship to the child and facilitate the integration of the traumatic experience into their personal and family narrative. Professionals must develop in depth awareness of their biases and attitudes, have an ongoing training on how to respond to the parents' needs, facilitate therapeutic change and accompany families through the course of their adult child's illness trajectory.

ABSTRACT

Introduction Children who are diagnosed with psychosis often rely on their parents for prolonged care. The impact of such care is partially understood as most studies use quantitative methods and pre-existing theoretical frameworks that limit their investigation to emotional burden, and emotional responses. Aim Explore the parents' lived experience of caring for a child with psychosis. Method A hermeneutic phenomenological design was used with a sample of 16 parents of children with psychotic disorders who were hospitalized or attended the outpatient clinic of a large psychiatric Greek hospital. Results Identified themes were as follows: (i) the psychosis experience, (ii) redefinition of the parent-child relationship over the course of the disorder and (iii) challenges of parenting a child with psychosis. Discussion 'Caring for an intimate stranger' reflects the parents' overall experience, involving changes in the parent-child relationship, ambivalence towards caretaking and profound guilt, compensated by self-sacrifice parenting practices.

IMPLICATIONS FOR PRACTICE

Findings highlight the necessity to train mental health professionals to provide individualized information; facilitate family communication; address the parents' guilt, ambivalence, meaning attributions that compromise adjustment; and support them through the challenges of parenting a son or daughter with psychosis.

Moral Professional Personhood: ethical reflections during initial clinical encounters in nursing education

Moral agency is an important constituent of the nursing role. We explored issues of ethical development in Greek nursing students during clinical practice at the beginning of their studies. Specifically, we aimed to explore students’ lived experience of ethics, and their perceptions and understanding of encountered ethical conflicts through phenomenological analysis of written narratives.

The process of developing an awareness of personal values through empathizing with patients was identified as the core theme of the students’ experience. Six more common themes were identified. Development of the students’ moral awareness was conceptualized as a set of stages, commencing with empathizing with patients and nurses, moving on to taking a moral stand and, finally, concluding by becoming aware of their personal values and showing evidence of an emerging professional moral personhood. The notions of empathy, caring and emotion were in evidence throughout the students’ experience. Implications for practice and nurse education are discussed.

A Proposed Model of Health Professionals' Grieving Process

This article proposes a model that conceptualizes health professionals' reactions to the multiple deaths of their patients, in terms of loss and grief. It suggests that grieving is both an individual and a social-interactive process that may be understood in terms of an ongoing fluctuation between experiencing grief reactions by focusing on the loss experience, and repressing or avoiding grief reactions by moving away from it. This fluctuation allows professionals to attribute meaning to the death of individual patients, and to transcend these losses by investing in life and living. The interaction between individual idiosyncratic factors (“life style”) and environmental factors (“work style”) is described in terms of how they affect the grieving process. Special consideration is given to the individual and collective forms of grieving, and to the role of team support.

From Infertility to Successful Third-Party Reproduction: The Trajectory of Greek Women

The purpose of our phenomenological hermeneutic study was to explore the lived experiences of Greek infertile women who achieve a pregnancy through the use of sperm, oocyte, or embryo donation or surrogate motherhood. Semistructured interviews were conducted with 15 infertile women. Findings suggest that conceiving a child through assisted reproductive technologies (ART) is lived as a highly distressing experience, comprising long waiting periods for medical results, several failed attempts, and treatment options with uncertain outcomes. The analysis of women's accounts revealed a constitutive pattern, journeying between hope and despair, and three associated themes: (a) coping with uncertainty and treatment failures, (b) exploring options and decision making, and (c) being supported by spouse and professionals. Findings illuminate the specific meaning-based coping processes, decision-making patterns, and sources of support that help women who pursue treatment until they give birth to a child, to manage highly stressful situations and critical decisions.

Impact of Job Satisfaction on Greek Nurses' Health-Related Quality of Life

Background

Employee job satisfaction and its relationship with health and quality of life has been an issue of major concern over the past decades. Nurses experience difficult working conditions that affect their job satisfaction, health, and quality of life.

Methods

A cross-sectional study was undertaken in three general hospitals and their respective health centers. Stratified random sampling by level of education was used, and 508 nurses and nursing assistants were included. A self-administered anonymous questionnaire, which included the Measure of Job Satisfaction, the 36-item Short Form Health Survey, as well as demographic details, education, and work conditions data, was used.

Results

Greek nurses were found to be dissatisfied with their job according to the total score of the job satisfaction scale, although personal satisfaction and satisfaction with support had had higher scores. Their general health was reported as average, because of physical and mental health problems, low vitality, low energy, and increased physical pain. Multivariate linear regression analysis revealed that males and those wishing to stay in the job had higher physical and mental health. Increased job satisfaction was related to increased physical and mental health.

Conclusion

Although Greek nurses are not satisfied with their work, those with high levels of job satisfaction had better health-related quality of life. The findings suggest that improvement of the work environment would contribute to a healthier and more satisfied nursing workforce.

Surrogacy: The experience of Greek commissioning women

BACKGROUND

Available studies on surrogacy are extremely limited. Findings suggest that surrogacy is experienced as problem free, with a significant number of commissioning mothers maintaining contact with the surrogates over time.

AIM

To explore the experiences of Greek commissioning women regarding the surrogacy arrangement and birth of a child through surrogacy.

METHODS

The data of this study were collected from 7 intended mothers who had either a long history of infertility or serious health problems. Interviews were tape-recorded, transcribed and analysed employing content analysis.

FINDINGS

The analysis of the women's accounts revealed three themes: (a) a shared journey, (b) the birth of a long-awaited child, and (c) the surrogacy disclosure. The surrogacy process became the women's affairs, with their partners offering backstage support. A very close bond was developed with the surrogates, characterised by daily contacts and care-giving behaviours. While this bond was abruptly discontinued after the child's birth, it was interiorised with all participants being grateful to their surrogate. The timing and content of the surrogacy disclosure to family and child(ren) were carefully chosen by participants, who avoided providing information when egg donation was involved.

CONCLUSION

Findings are reassuring for women who want to parent a child through a surrogate arrangement, and suggest that the availability of counselling services may help intended mothers to cope with disclosure issues.

Adolescents' reactions after a wildfire disaster in Greece

This cross-sectional study examined the factors associated with higher levels of posttraumatic stress disorder (PTSD) and depression symptoms in 1,468 adolescents, 6 months after a wildfire. The rate of probable PTSD was 29.4% and 20% for probable depression. Findings on predisaster, disaster-related, and postdisaster factors revealed that disaster-related factors-specifically objective and perceived threat to self and others-were associated with symptoms of PTSD but not depression. Predisaster life events, postdisaster losses, and escape-oriented coping strategies were associated with higher levels of both PTSD and depression symptoms, while control-oriented coping and perceived social support were differentially associated with symptoms of and depression. Findings have implications for the assessment and treatment of traumatized and depressed adolescents after a disaster.

'The patient is my space': hermeneutic investigation of the nurse-patient relationship in critical care

BACKGROUND

The nurse-patient relationship has been postulated to lie at the core of nursing care. However, it is unclear how this concept applies in critical care, as a great majority of critically ill patients are unable to communicate.

AIMS

Through a phenomenological hermeneutical perspective, we aimed to explore intensive care nurses' perceptions and meanings regarding their interpersonal relationship with critically ill individuals.

METHODS

A Heideggerian hermeneutical approach was used to design the study and analyse the data, which were collected through repetitive interviews with 12 intensive care nurses.

RESULTS

Critical care nurses report to experience deep relationships with patients, which seem to be mediated by the ongoing contact with patients' bodies. These relationships evoke intense feelings of love, empathy and care and affect how nurses perceive and make sense of their role and their world. The identified core theme of their experience is entitled 'syncytium', which describes a network of closely connected cells. According to participants' perceptions, nurse and patient affect each other reciprocally and are mutually dependent upon each other. In Heideggerian terms patients provide nurses with opportunities to experience 'authentic care' and they participate in their 'being-in-the-world', thus they are central in nurses' meanings about their role and existence. Other elicited themes that account for the perceived nurse-patient relationship include the spatiality/temporality of the relationship, nurses' perceptions and meanings attributed to their role and nurses' perceptions of death.

CONCLUSIONS

Critical care nurses appear to experience their relationships with patients intensely. These relationships are invested with meanings and elicit powerful feelings over a shared course with patients. Patients are central in nurses' meaning-making process and role perception.

RELEVANCE TO CLINICAL PRACTICE

These findings have implications for the educational preparation of critical care nurses and their psychological support.

Can individuals who are specialists in death, dying, and bereavement contribute to the prevention and/or mitigation of armed conflicts and cycles of violence?

Specialists in death, dying, and bereavement and their consequences for individuals, families, and communities have experience and research findings that are relevant to an understanding of the reactions of individuals faced by deadly violence. At such times, powerful emotions and ingrained patterns of thought and behavior can given rise to disproportionate responses that may feed into cycles of violence. An extended table shows how professionals helping individuals and families faced with violent death share common aims with those aiming to help larger social units faced with armed attacks. It follows that these professionals should work together to improve death education, to prepare people for possible deadly violence and, where possible, to suggest alternatives, to create secure places and relationships in which communication becomes possible, bad news can be broken and understood, feelings examined, differences reconciled, and people can redirect anger into the prevention of escalation rather than its perpetuation. All of these activities hold out hope that cycles of deadly violence can be broken as well as mitigating the consequences when they are not. The undoubted success of the worldwide palliative care movement resulted from the recognition of serious deficiencies in existing services, the provision of an inclusive, holistic, program that extends across medical, social psychological, and spiritual realms of discourse, providing care for patients and their families, irrespective of wealth, race, religion, and political persuasion, by dedicated leaders and teams backed by education and information services and organized across geographical boundaries. It is argued here that the time is ripe for a similar commitment to bring to an end the scandal of armed conflict by a similarly multidisciplinary, multicultural effort to relieve the suffering that both causes and results from armed conflict. This must remain independent of race, religion, political persuasion, and opposing sides and could build upon the leadership, educational models, information services, and international organizations that already exist for the provision of palliative and bereavement care.

Quality of life of adolescent and young adult survivors of childhood cancer

The purpose of this study was to assess the quality of life of Greek survivors of childhood cancer by addressing the physical, psychological, spiritual, and social dimensions of their functioning. The SF-36 Health Survey and the Quality of Life Questionnaire, which was designed for this study, were used. Survivors' scores on most subscales of SF-36 were similar to those of controls, despite some difficulties in their daily activities. They perceived self as more susceptible to health problems, but also more mature and grounded. Generally, they seem to adapt well and focus on the positive aspects of their cancer experience, which enhances the meaning and quality of their life.

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.

Psychosocial functioning of young adolescent and adult survivors of childhood cancer

GOALS OF WORK

The present study aimed to assess the psychosocial well-being of Greek adolescent and young adult survivors of childhood cancer and, in particular, self-esteem, anxiety, coping strategies, and social functioning.

PATIENTS AND METHODS

The sample comprised 103 Greek childhood cancer survivors and 135 healthy controls. The Battle Culture-free Self-esteem Inventory (BCSEI), the Spielberger State-Trait Anxiety Inventory (STAI), the Lazarus and Folkman Ways of Coping, and 36-item short-form instruments were used along with The Questionnaire for the Quality of Life.

MAIN RESULTS

Survivors scored higher than controls on all STAI subscales, but on State, the difference was statistically significant only for female adults, while on the Trait subscale, for the entire group. Survivors scored lower on Personal and higher on Lie subscale of BCSEI, by comparison to controls. When coping with stressful events, the use of self-blame strategies and wishful thinking were more frequent among controls, while distancing strategies more common among survivors.

CONCLUSIONS

The long-term psychological functioning of Greek survivors of childhood cancer is satisfactory, with emotional difficulties, such as increased anxiety and lower self-esteem, receding over time. Survivors experience personal growth and mature through trauma as they develop a positive view of the impact that the cancer experience has upon their life.

Empirically based recommendations to support parents facing the dilemma of paediatric cadaver organ donation

The aim of the study was to describe the challenges donor and non-donor parents encounter before, during, and after the organ donation decision, and to identify parents' needs and expectations from health care professionals. A further aim was to propose evidence-based recommendations for effectively introducing the option of donation, and supporting families through the grieving process. This study was undertaken as part of a larger research project investigating the experiences of Greek parents who consented or declined organ and tissue donation, using a qualitative methodology for data collection and analysis. The experiences of 22 Greek bereaved parents of 14 underage brain dead children were studied through semi-structured interviews. Parents' decision-making process was described as challenging and fraught with difficulties both before and after the donation period. Identified challenges were clustered into: (a) personal challenges, (b) conditions of organ request, and (c) interpersonal challenges. Parents' main concern following donation was the lack of information about transplantation outcomes. Findings led to a list of recommendations for nurses and other health professionals for approaching and supporting parents in making choices about paediatric organ donation that are appropriate to them, and for facilitating their adjustment to the sudden death of their underage child.

The decision-making process of parents regarding organ donation of their brain dead child: A Greek study

The purpose of this qualitative study, which was part of a larger study on parental bereavement, was to explore the decision-making process of parents who were invited to donate the organs and tissues of their brain dead child. Research objectives were to investigate how parents reach a decision and which factors affect consent or refusal regarding organ donation. The experiences of 22 parents of 14 brain dead children, hospitalized in two pediatric intensive care units (PICU) in Athens, were studied through semi-structured interviews. Data collection and analysis of the overall study were performed according to grounded theory methodology. Factors that influenced parents' decisions were identified and classified into (a) personal factors, (b) conditions of organ request, (c) parents' prior knowledge and experience with organ donation or serious illness, and (d) interpersonal factors. Findings can help care providers to facilitate the decision-making process and respond to parental needs while taking into account the socio-cultural context within which decisions are made. The donation request is meaningful and effective when it is integrated into an approach that offers ongoing support to parents who are faced with the unexpected death of their child.

Parental grief following the brain death of a child: does consent or refusal to organ donation affect their grief?

The purpose of this study was to investigate the grieving process of parents who were faced with the dilemma of donating organs and tissues of their underage brain dead child, and to explore the impact of their decision on their grief process. A grounded theory methodology was adopted and a semi-structured interview was conducted with 11 bereaved parents who consented to, and 11 parents who declined organ donation. Findings suggest that the core themes that characterize their grief and the main variables that affect their grieving process are similar for both donor and non-donor parents. Consent or refusal of organ donation per se does not seem to affect the overall grieving process. It is the meaning attributed to the act of donation that affects how parents perceive the child's death and subsequently facilitate or hinder their adjustment to loss.

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.

Accelerometer feedback to promote physical activity in adults with type 2 diabetes: a pilot study

This study examined whether giving activity feedback to obese, sedentary adults with Type 2 diabetes would improve their adherence to a home-based walking program. 49 subjects were recruited. Ten failed a treadmill cardiovascular test. Another 9 dropped out before the intervention, and 4 dropped out during the intervention. The remaining 26 adults (14 women, 12 men; age M = 48.1 yr., SD = 7.1) received behavioral counseling monthly for 3 mo. regarding exercise. All subjects wore a triaxial accelerometer during these 3 months. Randomly, half of the subjects were blind to the data from the accelerometers, i.e., no feedback, and had counseling based on their self-report diaries. The other half had access to the accelerometer data, got a computerized graph of their physical activity for the period between counseling sessions, and had counseling based on these objective data, i.e., feedback. The feedback group showed an increase in exercise over the 3 mo. The nonfeedback group showed an increase in activity at 1.5 mo. but reverted to their baseline exercise levels at 3 mo. However, analysis of variance showed there was at least an 8% probability that this effect was due to chance, so the hypothesis that feedback would improve exercise adherence could not be supported. Further studies with larger sample sizes and greater control of experimental conditions are needed to determine the utility of objective activity feedback.

Dysthymic reactions of women undergoing chorionic villus sampling for prenatal diagnosis of hemoglobinopathies or karyotyping

OBJECTIVES

The aim of the study was to investigate the levels of anxiety and depression, as well as liability to depression, of women undergoing chorionic villus sampling (CVS) due to the risk of giving birth to a child suffering from hemoglobinopathy, or trisomy.

METHODS

The study population consisted of 309 women who attended the Fetal Medicine Unit of Alexandra Hospital, University of Athens, Athens, Greece for a first trimester chorionic villus sampling (CVS). One hundred and fifty-nine women (group A) underwent CVS due to increased possibility of carrying an embryo with beta-thalassemia, while 150 women had the procedure because of an increased nuchal translucency measurement, or a positive first trimester biochemical screening (group B). Three hundred and nine women, matched by age and gestational age with those of the study group, who were not subjected to any diagnostic intervention formed the control group. We further investigated differences of dysthymic reactions among three subgroups of women at risk for hemoglobinopathy: (a) women undergoing their first pregnancy; (b) women who had been pregnant more than once but had not any children, and (c) women who had given birth to at least one healthy child, irrespective of previous terminations.

RESULTS

The incidence of clinically elevated levels of anxiety and depression was significantly higher in groups A and B compared to controls (p<0.001), while no significant difference was found in mean anxiety and depression, as well as the liability to depression among the three groups. Clinically elevated levels of depression were found in 10.1 and 4.7% of the women of the hemoglobinopathy and karyotyping group, respectively. Especially women who had no children, due to previous pregnancy terminations presented significantly higher incidence of elevated depression compared to women who were pregnant for the first time, or women who had given birth to at least one healthy child in their life.

CONCLUSIONS

The findings of this study highlight the necessity of training medical and nursing personnel to understand and respond to the psychological and social needs of women undergoing CVS due to increased risk for hemoglobinopathy, and especially to those who have no children and who have a history of pregnancy termination due to an affected fetus.

Greek nurse and physician grief as a result of caring for children dying of cancer

This descriptive study explored and compared the grief responses and experiences of Greek physicians and nurses who provide care to children dying of cancer. Interviews were conducted with 14 oncologists and 16 pediatric oncology nurses. Data were subjected to a combination of qualitative and quantitative methods of analysis. For both groups, the dying process and death of children were highly stressful experiences and triggered a grieving process. Differences, however, were observed in terms of the way these two groups (a) perceived the loss of the child and (b) expressed or avoided their grief. It became apparent that health professionals' grieving process was affected by how they perceived their role, interventions, and contribution in the care of the dying child, which in turn was influenced by the social and cultural context in which care is provided to children with cancer. Findings suggest that despite the distress caused by children's death, both nurses and physicians identified specific rewards they reaped from caring for children who are terminally ill.

Job-related stress among nursing personnel in Greek dialysis units

The purpose of this study was to describe specific work-related factors that contribute to increased levels of stress experienced by nursing personnel, and to compare their impact on nurses and assistant nurses who work in Dialysis Units (DU) to those who work in Peritoneal Dialysis Units (PDU) in Greece. The sample of the study consisted of 682 members of nursing personnel working in DU and in PDU in Greek Hospitals. The collection of data was done by means of a questionnaire. The latter included questions about the motivation of nursing personnel for having chosen to work in these units along with questions about the stress factors related to the patients and their care, the role of the nurse in the unit, and the working conditions. According to the results of the study, the percentage of nursing personnel working in DU or PDU by their own choice was 71% and 8.3% respectively, whereas the rest of the staff were placed there irrespective of their preferences, by the Administrators. Among nursing personnel who had chosen to work in DU, the reported motives that contributed to their decision were the absence of a night shift (27.8%), and working in a closed unit. The main motive that incited nursing personnel to work in PDU was the acquisition and the application of specialized knowledge. The percentage of nursing personnel working in DU that expected high levels of job satisfaction was 77%, whereas the corresponding percentage for nursing personnel working in PDU was 65%. However, only 44% and 37% of the nursing personnel working in DU and PDU reported high levels of job satisfaction. The most important stressors related: i) To the patient: were the risk of contamination (79% DU, 84% PDU) and the death of a patient (77% DU, 80% PDU). 2) To the role of nursing personnel in the unit: were increased responsibilities (65% DU, 37% PDU), low involvement of the nursing personnel in decision making (58% DU, 54% PDU), and low professional status of nursing personnel. 3) To the working conditions: were the shortage of nursing personnel (74% DU, 99% PDU), limited material (74% DU, 57% PDU), the closed environment (75% DU, 64% PDU) and the daily work routine (78% DU, 61% PDU). In conclusion, we can say that working in DU and PDU provokes increased stress in nursing personnel, even though the implicated stress factors differ between these units.

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

The purpose of this transcultural descriptive study was to explore the subjective experiences of 63 oncology and critical care nurses who provide care to dying children in Greece and Hong Kong. Semistructured interviews were conducted with 39 Greek and 24 Chinese nurses who described their experiences and responses to the dying process and death of children. The data were analyzed qualitatively and quantitatively, and nurses' responses were compared for their work setting (oncology versus critical care) and their ethnic background (Greek versus Chinese). Findings revealed that most nurses experience a sense of helplessness when caring for a dying patient and difficulties in their communication with the child and parents during the terminal phase of the disease. The large majority acknowledge that the impending or actual death of a patient elicits a grieving process, which is characterized by a fluctuation between experiencing and avoiding loss and grief. Greek and Chinese nurses differ in their expression of their grief and how they attribute meaning to childhood death. Despite the suffering caused by multiple deaths, nurses report significant rewards from caring for chronically and acutely ill children, and the majority are satisfied with their job, despite the difficulties they encounter, in both countries, mostly as a result of shortage in personnel and cooperation problems with physicians.

Mutual Support among Nurses who Provide Care to Dying Children

The purpose of this study was to explore the sources, nature, and effectiveness of mutual support among nurses who are exposed to the death of children and to compare the experiences between a group of pediatric oncology nurses and a group of critical care nurses. Semistructured interviews were conducted with sixteen pediatric oncology nurses and twenty-three critical care nurses. Qualitative analysis was used to analyze the data. Findings revealed that (1) nurses relied more on their colleagues for support than on their relatives and friends; (2) the nature of the support they sought involved informational, clinical/practical, emotional, and meaning-making support; and (3) different forms of mutual support were encouraged in the two units, depending on individual needs and the unit's goals, philosophy, and implicit rules about expected behavior in the face of death and dying. Educational and clinical implications are briefly discussed.

Experiences of mothers in five countries whose child died of cancer

Although increasing attention is being focused on the emotional aspects of caring for dying children and their families, few research reports concentrate on the experiences of mothers, particularly in different countries. This article describes the findings of an exploratory, descriptive study that investigated the experiences of mothers from five different countries who each had a child die from cancer in the past 6 months. Principal investigators, members of the International Work Group on Death, Dying, and Bereavement, conducted semistructured interviews with 21 mothers in their own countries. No culturally related differences were noted among mothers, and the mothers' recall of their experiences are more similar than different. All mothers, irrespective of country, described similar reactions to the diagnosis, management of the end-stage illness, and challenge of coping with bereavement. Lessons learned from this project provide suggestions for future research across countries.

Training health professionals in caring for dying children and grieving families

In most industrialized countries today, the death of a child is a rare phenomenon. When it occurs, however, it is usually within a hospital setting, after the child has received complex and often long-term medical care aimed at curing or controlling a serious disease. Thus, health professionals are increasingly exposed to the dying process and death of a child with little prior education to help them deal with the particular needs of young patients and minimal preparation in recognizing and handling their personal reactions in the face of death. Comprehensive training programs in pediatric hospice care could help professionals cope with the growing and unique needs of terminally ill children and of their families but these should be differentiated from training programs designed for the terminal care of adult patients. The purpose of this article is to describe and discuss some of the challenges involved in the training of health professionals (pediatricians, nurses, psychologists, social workers, clergy) who wish to provide services to dying children and grieving families. These challenges include (a) definition of educational objectives, (b) selection of teaching methods and content of training, (c) definition and teaching of emotional involvement, (d) support of training participants, (e) promotion of interdisciplinary collaboration, (f) evaluation of the training process and its outcomes, and (g) background and skills of educators. The challenges are discussed and references are made to illustrate how they were met by a 600-hour training program on home-based palliative care for children dying of cancer conducted at the University of Athens.

Death of a child at home or in hospital: experiences of Greek mothers

The purpose of this study was to investigate the experiences of Greek mothers who cared for a child dying of cancer at home or in the hospital, and to highlight some of their major needs during the terminal period. Fifteen mothers were interviewed and both quantitative and qualitative procedures were used to analyze the findings. Ten families (67%) chose to care for the child at home without having access to home care services, while the remaining five sought hospital care. Their decision was primarily based upon the child's expressed wish and parental preference. The family network played a significant role in supporting the mother-child unit, especially when death occurred at home. Mothers assessed positively the services provided by nurses and social workers, and had expectations that physicians would support them on a psychological level during the terminal period. The care of the dying child is influenced by cultural factors predominant in Greek society and some of the findings are discussed in this light.

Factors contributing to the development of burnout in oncology nursing

The purpose of this study was to determine whether oncology nurses experience higher levels of burnout compared to nurses working in general hospitals, and to further identify the personal and environmental factors that contribute to the development of emotional exhaustion, depersonalization and lack of personal accomplishment. Seven tools, measuring a selected set of demographic, psychological and occupational variables, were administered to 217 female nurses who worked in oncological hospitals and 226 nurses who worked in general hospitals in the area of Athens. Measures used in the study included the Maslach Burnout Inventory, the Hardiness Scale, the Ways of Coping Scale, the Life Style Scale, the Type A Behaviour Scale, a Job Stress Questionnaire and a General Information Questionnaire. No statistically significant difference was revealed in the degree of burnout experienced by nurses in oncology and those in general hospitals. Multiple linear regression analysis suggested that personality characteristics seem to predict a greater percentage of the variability of the burnout experienced than occupational and demographic variables. A sense of personal control over the things that happen in life and in the work environment was found to protect nurses from emotional exhaustion, depersonalization and lack of personal accomplishment.

Adolescents dying from cancer

'Dying' and 'adolescence' are both transitional periods, characterized by change, loss, separation, along with a search for meaning and identity. It is therefore important for those involved in the care of dying adolescents to possess the necessary skills for understanding the reactions and needs of young people who attempt--through interaction with others--to give meaning to both their life and their approaching death. Effective intervention necessitates the ability to encourage open communication and to interpret the symbolic language that adolescents use to express their feelings, concerns and needs. Examples from clinical experience are presented and discussed in an attempt to enhance appropriate support during those critical moments. Dying is a social and dynamic process and through meaningful interaction and honest communication, it may become an enriching experience for both the adolescent and those involved in his/her care.