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Death and the oncology nurse: A qualitative study to understand the adult inpatient oncology nurse experience coping with the death of patients

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DEATH AND THE ONCOLOGY NURSE:
A QUALITATIVE STUDY TO UNDERSTAND
THE ADULT INPATIENT ONCOLOGY NURSE
EXPERIENCE COPING WITH THE DEATH
OF PATIENTS
BY
ELIZABETH CATHERINE BLASIAK
A Thesis Submitted to the School of Graduate Studies
in Partial Fulfillment of the Requirements for the Degree of
Master of Science
Southern Connecticut State University
New Haven, Connecticut
May 2010
UMI Number: 1486125
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DEATH AND THE ONCOLOGY NURSE:
A QUALITATIVE STUDY TO UNDERSTAND
THE ADULT INPATIENT ONCOLOGY NURSE
EXPERIENCE COPING WITH THE DEATH
OF PATIENTS
BY
ELIZABETH CATHERINE BLASIAK
This thesis was prepared under the direction of the candidate's thesis advisor, Dr. Olive
Santavenere, Department of Nursing, and it has been approved by the members of the candidate's
thesis committee. It was submitted to the School of Graduate Studies and was accepted in partial
fulfillment of the requirements for the degree of Master of Science.
Olive Santavenere, Ph.D., RN
Thesis Advisor
Cesarina Thompson, Ph.D., RN
Second Reader
Lisa Rebeschi, MSN, CNE, RN
Department Chairperson
ldra C. Holley, Ph.D.
)ean, School of Graduate Studies
May 6 .
2010
Date
i
ABSTRACT
Author:
Elizabeth Catherine Blasiak
Title:
DEATH AND THE ONCOLOGY NURSE: A QUALITATIVE STUDY
TO UNDERSTAND THE ADULT INPATIENT ONCOLOGY NURSE
EXPERIENCE COPING WITH THE DEATH OF PATIENTS
Thesis Advisor:
Dr. Olive Santavenere
Institution:
Southern Connecticut State University
Year:
2010
The purpose of this descriptive qualitative study was to explore, describe and analyze
nurses' experiences in coping with the frequent death of patients in the adult inpatient oncology
setting. Ten nurses, who were members of the Oncology Nursing Society, participated in the
study. A mailed questionnaire was used to elicit written narrative responses. Content analysis
determined the major themes. The results of the study provided data related to nurses'
perceptions of ways they handled their grief. The finding indicated that the nurses supported
each other and shared their grief with losses of patients in the oncology settings. Responses
reflected individual ways for coping with their loss of patients. The majority of nurses indicated
that they were committed to continue working in oncology because of the reward and satisfaction
in their professional practice. The nurses noted that supportive services would be useful in their
roles as oncology nurses.
ii
To my mother, Kay, who inspired me to become an oncology nurse. Your wisdom, guidance,
and support have made all of my accomplishments possible. To me you are a cancer survivor,
oncology nurse, mother, but most importantly my life-long best friend.
Mom, thanks for everything.
iii
ACKNOWLEDGEMENTS
I would like to thank Dr. Olive Santavenere for her support and guidance while preparing
this thesis. Her constant encouragement to persevere through this process and her personal
commitment allowed for the completion of this endeavor. I would also like to thank the entire
faculty and staff of the Nursing Department. Throughout my academic journey, which began as
an undergraduate, the faculty and staff have always been there to assist me in reaching my goals.
iv
TABLE OF CONTENTS
CHAPTER ONE: INTRODUCTION
2
Purpose of the Study
6
Objectives
6
Conceptual Definitions
7
Grief
7
Stress
7
Coping
7
Bereavement
7
Compassion Fatigue
8
Burnout
8
Resilience
8
Significance of the Study
8
CHAPTER TWO: REVIEW OF LITERATURE
10
Theoretical Framework
10
Stage one: Denial and Isolation
11
Stage two: Anger
11
Stage three: Bargaining
11
Stage four: Depression
12
v
Stage five: Acceptance
12
Review of Research
13
Stress and Bereavement
13
Coping and Support
16
Summary
22
CHAPTER THREE: METHODS
23
Researcher Credentials
23
Purpose of the Study
23
Research Design
24
Sample Selection
25
Data Collection
25
Ethical Considerations
27
Data Analysis
27
CHAPTER FOUR: RESULTS
29
Demographic Data
29
Hours Worked
29
Years of Practice
29
Educational Preparation
30
Analysis of Data
30
Experience with Frequency of Death
31
Activities and Rituals Employed
31
Impact of Presence with Death
33
Memorable Experiences
34
vi
Peaceful Death
37
Family-Nurse-Relationship/Contact and Service Attendance
38
Sharing the Experience
39
Coping
39
Coping Resources
40
Surviving Patients
41
Stress
43
Nurse Retention
43
Resilience
44
CHAPTER FIVE: DISCUSSION AND IMPLICATIONS FOR PRACTICE
46
Limitations of the Study
55
Recommendations for Future Research
56
APPENDIX A
58
APPENDIX B
59
APPENDIX C
60
APPENDDCD
62
REFERENCES
65
vii
LIST OF TABLES
Table 1
Demographic Data of Participants
30
viii
CHAPTER ONE: INTRODUCTION
Kay has been practicing as an oncology nurse for three years. She had her heart set on
working with cancer patients when she began nursing school. From a young age, Kay wanted to
make a difference, to touch lives, and someday make an impression on possibly another
generation of nurses. As she began her oncology role, Kay met many new patients. Some were in
the midst of a long battle with cancer, while others were closer to death. She lacked experience
and was always optimistic so that she encouraged continued hope and support regardless of the
patient's prognosis. During her first year as a nurse, she met three patients who especially
touched her life. These middle-aged men included a gruff ex-police officer, a reserved professor
from an Ivy League school, and a wealthy banker. All these patients had a diagnosis of Acute
Myelogenous Leukemia (AML) in April of the same year. They had experienced a similar
regimen of chemotherapy within weeks of each other. The early weeks of chemotherapy usually
results in many complications, such as the need for repeated transfusions with blood, risk for
infection, overwhelming fatigue, along with nausea and vomiting.
Each man spent about a month in the hospital. Kay discovered the gruff police officer
was only gruff on the outside, and had two sons who were officers as well. When the police
officer had a temperature elevation, he would lay with a wet face cloth draped over his face with
his oversized belly exposed to the whole unit. He had an interesting sense of humor, and always
wanted to laugh, while crying on the inside.
2
The reserved professor would always change into khakis and a button up shirt despite
what the day had in store for him. Each day he would get up and walk to his favorite coffee shop
down the street from the hospital. He continued to follow his routine daily activity even when his
immune system was weakened from the chemotherapy. He would put on gloves and a mask and
sneak away for a cup of coffee. He had two daughters who lived out of state. His wife seemed to
be the exact opposite of her husband. The professor was proud and private. The day he found out
he was in remission, he looked at Kay with endearing eyes, and she thought he would hug her,
but he only gave her a fatherly tap on her head.
The banker was also private and had a dry sense of humor. He would make jokes that
were easily missed if one were not paying attention. He never came into the hospital without his
laptop and some work from home. He always gave Kay advice on how much money she should
have in savings. When Kay and her husband were looking at new homes, he had suggestions on
how to get a good mortgage. The banker's wife always brought dinner for both to share. She
always brought a bottle of wine to drink with the homemade dinner. Kay made this discovery
when she disrupted their dinner one evening to assess the status of the banker. Kay later found
that the banker's wife had a problem with drinking that escalated as his treatment continued.
Each man faced setbacks over the course of almost a year and all three men developed
overwhelming infections along with multiple complications. They had repeated admissions for
these problems, spending only days at home with weeks to months in the hospital. The snow
began to fall and Christmas was just around the corner. Kay who was the primary nurse for the
three patients recognized that each man's condition was deteriorating. The police officer wanted
to go home and have visits from hospice nurses. Kay arranged for home hospice care. As she
wheeled him to the elevator, she hugged his wife, his two sons, and finally him. The gruff
3
policeman began to cry and said, "Thank you, for everything, and be good." Kay was
overwhelmed with tears and quickly left. She was not sure if it was unprofessional to cry in front
of her patient and his family. A week later his wife called the unit to let Kay know he died on
December 26th.
The professor's disease also progressed and his prognosis was very grim. His daughter
lived a distance across the country, and had taken a month off from work to be with her father.
Phone conversations between Kay and his daughter, now became one-on-one talks. The daughter
knew so much about Kay that it was obvious that the professor talked about her often. The
physicians determined that end-of-life discussions occurred with the professor and his family at
this time. The physicians asked Kay to help facilitate these discussions because she knew the
patient and family so well. The professor had advance directives for resuscitation. A few days
later, he was admitted to the intensive care unit where he died on January 20th.
The banker was fighting an overwhelming infection. His daughter was about to give birth
to a baby girl in April. He had told Kay he wanted to meet his new granddaughter. His wife's
drinking problem increased overtime. She came to the hospital as beautiful as ever, dressed in
tailored clothes and she only visited for an hour. He still wanted to be home waiting for his
granddaughter despite gradually becoming weaker. His wife agreed to seek counseling, and set
up nursing care for her husband at home. Kay called their home to see how the transition was
going. Unfortunately, he never knew his baby granddaughter because he died on April 13.
Kay was overwhelmed with the loss of these three men. The previous April her three new
patients had been diagnosed, and by the following April all three had died. She knew each man
and his family personally by this time and the losses continued to be distressing to her. Kay had
4
always tried to separate work from home, but she was not able to do so since she had cared for
them for a year. These were her patients and not strangers.
Her practice changed after that April. She began to consider other places where she could
practice and would not have to face the losses that saddened her. She was concerned about how
her co-workers would judge her if they knew how upset she was over the loss of these three men.
She felt alone and needed someone to talk with in order to help her deal with her own grief.
Nurses have the resources for patient and family support including social work and
pastoral care to assist them in managing the grief of patients and families. Nurses also need to
have the resources and support to manage their continuing losses of patients.
The lack of supportive programs for grieving nurses contributes to negative outcomes
(Brosche, 2003). It is evident that nursing is a stressful profession. Research has revealed that the
death of patients only adds to the stress that nurses endure. Boyle (2000) suggested that oncology
nurses have the potential to continue practicing while ignoring their own grief related to the loss
of patients. The loss of a patient starts a cycle that begins with nurse sadness and grief.
Ultimately, the cycle can lead to nurse stress and burnout, institutional high cost, unit turnover,
poor nurse-patient communication and lower quality patient care and patient satisfaction (Leiter,
Harvie, & Frizzell, 1998; Medland, Howard-Ruben, & Whitaker, 2004; Papadatou, Bellali,
Papazoglou, & Petraki, 2002). These research studies provide evidence that clearly indicated the
support needed for nurses to cope with the frequent losses.
Hospice and oncology nurses experience frequent death of patients while providing
knowledgeable physical and emotional care to patients and families. Nurses need to know how to
manage their own grief, the feelings that are provoked from these losses, and coping strategies
5
that could be used. This study will focus on the professional experiences of oncology nurses
who continually cope with the death of their patients.
Purpose of the Study
The purpose of this descriptive qualitative study was to explore, analyze, and understand
nurses' experiences in coping with the grief related to the loss of their patients in an oncology
setting. The goal of this study was to evaluate the following questions: How do oncology nurses
cope with the death of patients? What activities or rituals are oncology nurses who are grieving
the death of patients doing? How are oncology nurses impacted by the frequent loss of patients?
Research in this area may be useful in promoting the development of effective support programs
for oncology nurses who deal with grief and loss on an ongoing basis.
Burns and Grove (2004) describe the qualitative research approach as a holistic viewpoint
based on the beliefs that no single reality exists. Reality is different for every person, based on
individual perceptions. Reality can change over time, and what one knows is only meaningful in
a specific context or situation. Capturing the multiple realities that exist for the individual studied
is a fundamental belief of qualitative researchers (Streubert-Speziale & Carpenter, 2003). Death
is an extremely personal event for the individual who is dying and for those who are grieving the
loss. Every death experienced by the individual has significance and importance.
Objectives
1. Describe the experience when a patient dies in the oncology setting from the perception
of the nurse.
2. Increase the understanding of how the death of a patient can affect both one's nursing
practice and personal beliefs.
6
3. Identify methods, strategies, activities and rituals used by oncology nurses for coping
with the death of patients.
4. Discover the nurses' perceptions of supportive measures that help manage grief related to
the death of patients.
Conceptual Definitions
Grief. Grief involves an emotional response to any type of loss including an imminent or
actual death (Egan & Arnold, 2003). The state of mourning is the experience that is associated
with grief, such as crying, wailing, or moaning (Egan & Arnold).
Stress. It is a strain or pressure from an external trigger that can possibly produce a
physiological or emotional response (Kahn & Saulo, 1994). Psychologist Richard Lazarus
developed and tested a transactional model of stress (Lazarus, 1966; Lazarus & Folkman, 1984).
The theory presented stress to be a transaction. The transaction of stress includes an intake of
stress, the appraisal of the stress as expressed by the person, and finally an eventual response to
the stress. There is always a response to stress in this model. Appraisal serves as a mediator
between the person and the environment that is inflicting stress.
Coping. A response to stress and can be defined as the "constantly changing cognitive
and behavioral efforts to manage specific external and/or internal demands that are appraised as
taxing or exceeding the resources of the person" (Lazarus & Folkman, 1984, p. 141). This
definition focuses on the management of stressful situations; it does assume that mastery of the
situation is attainable. This definition highlights that coping is an ongoing process that one may
experience.
Bereavement. The emotions and behaviors experienced by a person who has suffered a
loss (Egan & Arnold, 2003). Bereavement occurs with the death of someone; the survivors
7
experience the loss of a loved one. The process of bereavement is specific because it occurs for
the survivors after a person has died.
Compassion Fatigue. A concept identified by Figley (1983) as natural "behaviors and
emotions resulting from knowing about a traumatizing event experienced by a significant other,
the stress resulting from helping or wanting to help a traumatized or suffering person" (p. 7).
Compassion fatigue can lead to burnout, desensitization to others' feelings, and a heightened
awareness of one's own mortality and the mortality of loved ones. Worley (2005) defined
compassion fatigue as a physical, emotional, and spiritual exhaustion that occurs from the stress
of caring for others. Ultimately, this fatigue can affect the care that one gives to another.
Burnout. A concept that is associated with the feelings of mental and/or physical
exhaustion that one may experience in the work environment (Freudenberger, 1974). Burnout
affects a worker's ability to perform tasks and can also affect one's interpersonal relationships
with peers, clients, and possibly with all relationships elsewhere (i.e. spouses, children, friends,
and families).
Resilience. This is the ability to bounce back or cope successfully despite substantial
adversity (Rutter, 1985).
Significance of the Study
In oncology nursing, the loss of a patient can be devastating to family and friends of the
patient and also to nurses. Oncology nurses are educated about the treatment and management of
disease. They often experience death on a daily basis when caring for dying patients. Supportive
programs provide needed assistance to nurses as they deal with the loss that continues daily.
Nursing leaders need to identify issues involved with grief and loss as experienced by oncology
8
nurses. Nurses must have formal support programs to guide them through their own personal
grief process.
Support programs are not in widespread use to assist nurses in dealing with grief
(Brosche, 2007). This increases the risk for nurses to grieve without the support of others. A
study by Ablett & Jones (2007) noted that staff training programs promote resilience. Reflective
practice may also help the staff to deal with the emotional issues related to end-of life care
(Ablett & Jones). Supportive program development for nurses in an oncology setting helps to
promote resilience and retain commitment in their role, while avoiding secondary problems such
as burnout, compassion fatigue, possible resignation, and effects on patient care (Ablett &
Jones).
9
CHAPTER TWO: REVIEW OF LITERATURE
Oncology nursing is a specialty that focuses on the care of patients with cancer. Nurses
promote care for their patients over an extended time. Because of frequent admissions to the
hospital, a close relationship often develops between patient families and nurses.
There is a stigma related to a diagnosis of cancer and the negative connotation that most
of society places on the illness (Lebel & Devins, 2008). Nurses find satisfaction in providing
supportive care to patients who have cancer. They use their nursing experience, clinical
knowledge, and establish relationships with patients to provide supportive care for patients to the
end-of-life. This research study gave a perspective of the way that nurses deal with the frequent
losses based on their experience over time.
Theoretical Framework
Kubler-Ross (1969) interviewed dying patients and identified a model that provided a
framework for human responses to the phenomenon of grief and the dying process. She defined
five stages of dealing with grief that includes the following: denial and isolation, anger,
bargaining, depression and finally, acceptance. She noted that individuals do not necessarily
follow these stages in the specific order. This model relates to the patients' perspective, but it can
apply to anyone who experiences grief, including family members and nurses.
10
Stage one: Denial and Isolation
Kubler-Ross (1969) stated that, "Denial, at least partial denial, is used by almost all
patients, not only during the first stages of illness, but also later on from time to time" (p. 52). It
provides a buffer after hearing unexpected shocking news that allows individuals to collect
themselves overtime and develop less radical defenses (Kubler-Ross). Kubler-Ross summarized
that denial involved the following statement: "No, not me, it cannot be true" (p.51). Patients can
isolate themselves from others during the period of denial. The patient becomes more guarded
and interacts less with nursing staff and family members for a time. Again, these stages of grief
are applicable to nurses grieving the loss of a patient.
Stage two: Anger
Anger occurs when the person can no longer maintain the denial. The individual has
feelings of rage, resentment, and envy which replaces the earlier stage of denial (Kubler-Ross,
1969). She described how difficult it is for the caregiver to cope during this stage because the
anger of patients displaces and projects it to others in all directions. It is important for nurses as
caregivers to recognize the expressed anger while continuing to provide understanding and
support when caring for patients during this time.
Stage three: Bargaining
Bargaining is another stage that can occur when a person is facing death. The dying
person seeks to postpone death in this stage (Kubler-Ross, 1969). The banker previously
described in this present study wanted to live long enough to see his new granddaughter.
Terminally ill patients may bargain to attend one last family event, such as an upcoming holiday
or wedding. Kubler-Ross stated, "Most bargains are made with God and are usually kept a secret
or mentioned between the lines or in a chaplain's private office" (p.95).
11
Stage four: Depression
Kubler-Ross (1969) defined this as a two-part stage. The terminally ill person faces
reactive depression and preparatory depression at this time. The individual processes the losses
that have resulted over time related to his or her illness and the individual is depressed. These
losses may include financial burdens, such as expensive costs for treatment or physical changes
that have occurred. Individuals may feel the loss of independence because they are unable to
carry out normal activities without assistance. These losses result in a reactive depression.
Kubler-Ross noted that caregivers who understand readily detect this type of depression and
provide supportive care accordingly. The second phase of depression is preparatory depression
described as, "one which does not occur as a result of a past loss but is taking into account
impending losses" (Kubler-Ross, p.99). The patient is preparing for death. Kubler-Ross
suggested that caregivers should be attentive to patients reaching this particular fourth stage. She
noted, "The patient is in the process of losing everything and everybody he loves. If he is
allowed to express his sorrow, he will find acceptance much easier" (p.99). The nurse plays a
significant role with this stage in supporting both patient and family. It is stressful for everyone.
Stage five: Acceptance
The concept of acceptance occurs when the person has moved through the other four
stages. The individual has come to accept his/her fate of death. Kubler-Ross (1969) clarifies that
this acceptance is only achievable when the person has had time to prepare for his or her own
death. Some patients never reach this final stage. With this stage the patient will be weakened,
tired, and tend to be withdrawn and become less verbal. Kubler-Ross stated, "Acceptance should
not be mistaken for a happy stage. It is almost void of feelings" (p. 124). This stage can be very
stressful for both the family members who are anxious with respect to the impending death. The
12
nurse has developed a trusting relationship at this time with patient and family and is concerned
for the welfare of everyone.
Kubler-Ross (1969) indicated that her concepts provided a new perspective, so that
caregivers might better understand the patient's behavior that occurs through the dying process.
The stages as defined by Kubler-Ross centered mainly on the dying person and not necessarily
on the family or caregivers.
Kubler-Ross' model (1969) and the five stages can be applied to both families and nurses
who are involved in the care of the dying person. Families who are losing a loved one to a
terminal illness experience the impending loss of their loved one on a daily basis. Nurses may
also experience anticipatory grief prior to the death of the dying patient and grieve for the loss of
the individual after death. This qualitative study of oncology nurses, who frequently experience
the deaths of patients, may provide useful evidence with respect to their grief experience and
ultimately to measures that can resolve their grief.
Review of Research
Stress and Bereavement
A number of research studies have assessed work related stress in nurses (Hinds,
Quargnenti, Hickey, & Mangum, 1994; Kulbe, 2001; Lyckholm, 2001; Oehler & Davidson,
1992). Qualitative and quantitative research studies have evaluated nurses in several oncology
settings, such as outpatient, pediatric, adult, and bone marrow transplant. These settings are high
areas of risk for work related stress. Several studies have concluded that the death of a patient is
stressful for nurses (Hinds, et al; Lees, & Ellis, 1990; Papadatou, Bellali, Papazoglou, & Petraki,
2002).
13
Rittman, Paige, Rivera, Stuphin, & Godown (1997) considered how caring for patients at
the end-of-life affected oncology nurses. The researchers assumed that nurses who worked in
oncology settings had a greater opportunity to understand the death and dying experience. They
noted that it would be useful to determine whether or not these nursing skills are innate, learned,
or a mixture of the nurse's personal experience and professional exposure. The sample included
oncology nurses with at least five years of nursing experience. Six nurses participated in the
qualitative study by providing written narratives. Emerging themes that related to the care of
dying patients included the following results: knowing the patient and the stage of illness,
preserving hope, easing the struggle, and providing privacy. Nurses who felt that they had
assisted patients to achieve a good death were able to begin the task of bereavement in the midst
of the end-of-life care and not just after the patient died. This small sample provided some
evidence related to the process of bereavement on the part of oncology nurses.
Another study examined nurses' narratives about end-of-life care (Mitchell, Sakraida,
Dysart-Gale, & Gadmer, 2006). The study included a sample of 19 nurses who practiced in a
variety of general medical or intensive care units. Each nurse had cared for patients for three
days prior to or at the time of death. The major thematic outcomes that emerged with this
qualitative study included the following: spiritual knowing, scientific explanation, and historical
understanding. The study findings indicated that the nurses frequently spoke of death in terms of
religious and spiritual beliefs. Nurses discussed their own religious beliefs when reflecting on a
patient's death and used these as part of their own acceptance of the death.
The theme of scientific explanation indicated that nurses approached death through
Spiritual Knowing, but they still relied on language grounded in science when explaining death.
The nurses often explained a death by the physiological changes that occurred with patients. The
14
researchers explained that "scientific language characteristically avoids personal, subjective, and
emotional explanations, seeking instead a detached objectivity" (Mitchell et al., p. 217). The
theme of historical understanding referred to the narratives that helped the nurses achieve a
greater understanding through the account of patient's death. In these situations, nurses described
not only the physiological changes but they listed the ultimate meaning of the series of events
related to the patient's death. The overall focus was not on how the nurses coped with the death
of the patients, but more on what each nurse experienced in caring for dying patients. The sample
in this study was small, but the findings related to the spiritual considerations with death may
give meaning to the nurses of the finality of life and their own mortality. Nurses continually
assess the physiological status of patients as a significant part of their nursing role, and they
intuitively know where the patient is in the dying process. Acquired knowledge occurs based on
the continued professional practice of nurses.
The closeness of a nurse-patient relationship has an effect on the amount of stress
experienced by the nurse when a patient dies. Studies based in pediatric settings have indicated
that nurses developed a close relationship with children (Hinds et al. 1994; Kushnir, Rabin, &
Azulai, 1997). The death of children was the most stressful situation for nurses in both of these
studies. Another study of pediatric oncology nurses indicated that deaths of favorite patients was
rated as the most stressful on the Stressor Scale by pediatric oncology nurses (De Carvalho,
Muller, De Carvalho, & De Souza Melo, 2005). Evidence from these studies indicated that
nurses experienced a considerable amount of stress when continually involved with the care of
dying patients. The death of young patients had special significance for the nurses.
Hinds et al. (1994) studied the factors of age and experience in nurses who worked with
dying patients to determine if these variables affected the stress levels experienced by nurses
15
who experienced the deaths of their patients. The findings indicated that younger nurses between
the ages of 30-34 made the strongest effort to respond to role-related stress, while nurses
between the ages of 40-44 made the least effort to respond to the stress. Responding to stress
refers to applying coping mechanisms, showing emotions, or sharing their experience of stress
with others. The study noted that there was a relationship between age of the nurses and the
responses to workplace stress in nurses.
Coping and Support
There is a concern that nurses may eventually be at a high risk for burnout and other
associated problems if they deal ineffectively with stressors related to their professional role.
Providing support for nurses who cope with death and dying would help to decrease the risk of
burnout and increase staff retention.
Oncology nurses have the potential to ignore their own grief when dealing with the loss
of patients (Boyle, 2000). Nurse administrators need to address these issues of grief experiences
and provide support to help nursing staff cope with the stress of the losses. Frequent deaths of
patients can lead to stress, burnout, poor practice, and ultimately loss of nurses to another setting.
Brosche (2003) said, "Recognition of the grieving process and utilization of effective and
appropriate coping skills can restore control to the griever. This effect is essential for the health
and well being of the nurse, the staff, and the hospital" (p. 179). Medland, et al (2004) also
indicated that burnout could lead to high turnover, absenteeism, negative effects on patient care,
and reduction in productivity in nursing staff. This reinforces the need for support systems to
help oncology nurses deal with the stress and loss of patients on a continuing basis.
Several other studies indicated that the use of support programs in oncology care settings
reduced stressors on nurses (Lewis, 1999; Molassiotis & Haberman, 1996; Spencer, 1993;
16
Thomas, 1995). Implementation of positive support measures such as informal discussions with
peers was helpful for the nurses who worked in hospice settings (Kulbe, 2001). Burkes (1990)
also noted positive outcomes with the implementation of support programs by incorporating a
number of helpful measures for nurses.
Nurses reported improved stress management along with enhanced problem solving skills
as an outcome of the programs. Burkes (1990) also noted that nurses recognized the need for
attention to issues such as conflict management that had contributed to the prevention of burnout
in the nursing staff.
Molassiotis and Haberman (1996) measured the potential for burnout and assessed job
satisfaction in a group of oncology nurses. This study revealed that nurses exposed to a support
program had decreased burnout and increased job satisfaction when compared to nurses who did
not have such a program.
A study by Ablett and Jones (2007) suggested that staff training and support programs
promoted reflective practice for nurses. Ten palliative care nurses from a hospice agency agreed
to participate in the study by having individual semi-structured interviews with the researcher.
Several themes emerged based on analysis of data and indicated that the nurses displayed a
strong sense of commitment to the care of their patients. They also felt they had a high degree of
control and autonomy in their role. The nurses also indicated there was a sense of purpose in
their nursing role that enabled them to enhance the quality of life of patients. Awareness of
spirituality was also one of the themes that related to hardiness with increased resilience and a
sense of satisfaction and purpose in their role. Reflective practice through support programs can
provide nurses with a growth experience to help them deal with the emotional impact of
commitment in a setting involved with end of life care.
17
The development of programs for oncology nurses needs to become a planned effort
within the work setting by providing successful measures related to grieving, stress reduction,
and measures for coping. This effort should lead to improved quality of care and satisfaction for
patients and family members as well as nursing staff. Lewis (1999) studied a number of ideas
relevant to the development of a bereavement program for oncology nurses. These ideas included
sending sympathy cards to families, keeping a death registry of patients who had died and having
an annual event for families. She developed a bereavement support group with a facilitator to
provide a time for discussion of nursing and staff concerns. The group of staff nurses met for 90
minutes at a time. Attendance was not mandatory and included a group of up to 10 people. It
took two years to develop, implement, and assess the effectiveness of this bereavement program.
The consensus of the nurses who had participated indicated that it was a helpful program. These
results were interesting in a qualitative sense, but they were not definitive in terms of
significance. It does give an indication of the need for this type of supportive program for nurses
in oncology settings.
Spencer (1993) studied how intensive care nurses dealt with grief when patients died on
the units and what type of support they received to help them deal with grief. Fifty-one nurses
completed a questionnaire with interviews held using a semi-structured format with only some of
the 51 participants. The study involved qualitative and quantitative components. Results of the
study indicated that 98% of the nurses noted they felt relief when a patient died. Most nurses
who participated thought that they already had established an informal support network with
their peers. Forty-one of the nurses who responded said they had received support from
colleagues. However, participants felt that a more structured support group with the availability
of a counselor would be helpful.
18
A study by Brosche (2007) included the use of a grief team with intensive care nurses.
She suggested that an informal needs assessment should be done using staff discussions to decide
if a grief team would be appropriate. The grief team was composed of nurses, chaplains, and
employee-assist staff certified in crisis management techniques individuals or licensed
counselors. This team would be available 24 hours a day and seven days a week. All deaths were
reported to the grief team. The grief team involved both patients and nurses. Brosche noted that
the intervention by a grief team minimized the effects of compassion fatigue, moral distress, and
the stress cascade in nurses
Lenart, Bauer, Brighton, Johnson & Stringer's (1998) study of intensive care nurses
examined the effects of grief support that included a phone call to the nurse by a member of the
grief support team. This study used phone calls and brown-bag sessions. A member of the grief
support team made phone calls to the nurses who were with patients at the time of death, as well
as the primary nurses for patients who had died. These calls provided the chance for the nurses to
vent any feelings and express immediate grief. Grieving nurses met in a quiet room allowing
them to express their grief. The quiet room was a serene place where families and nurses could
talk and feel "away" from the hospital. The brown-bag lunch sessions allowed nurses to discuss
their feelings. This enabled them to gain a better understanding about the grief process, receive
support from their peers, and reflect on their experiences.
Fitzpatrick, Bunevich, and Jones (2001) provided a one-day workshop for nursing staff
to promote healthy coping. The workshop was a day away from the work setting. It included the
support of social work and pastoral care staff. A number of techniques included group
discussions, education and massage to assist with management and relief from stress. The
program lasted for one day and was not an ongoing resource for the nursing staff. The program
19
presented a useful example of a specific plan to help reduce stress levels for oncology nurses. An
ongoing planned program of this type would be useful for agencies to develop as a way of
reducing the stress levels of oncology nurses..
Roberts and Snowball (1999) assessed how nurses working on two oncology units
described their approach to psychosocial aspects of care. Focus groups of 4 to 12 participants
were interviewed about their experiences. Nurses involved in the study had a range of experience
from 3 months to 7 years in oncology. This study highlighted the nurse-patient relationship that
occurred in an oncology setting. Nurses who initially admitted patients developed a degree of
closeness and involvement with them due to the length of their hospital stay and the high
frequency of repeated admissions. Roberts and Snowball defined nurses' social knowledge
through themes that emerged during the focus group interviews. Nurses' social knowledge had 5
core categories that were recognized. The categories included knowledge of nursing care,
knowledge of patients, knowledge of the ward, knowledge of nurses coping, and knowledge of
involvement.
The knowledge of nurses coping category identified methods of coping and the way in
which nurses learn from others. Roberts and Snowball (1999) measured awareness of self, selfconfidence in one's own abilities, recognition of limitations, and the signs of stress. The nurses
used these methods to cope with interpersonal stresses by talking with their peers about patient
deaths. Individual interviews were completed and focus groups developed as a way to have
ongoing discussions. In this study, the use of these coping methods was acknowledged by the
team of nurses. The outcome indicated that regular team meetings and talking with colleagues
was an important method for coping with the stresses. This study on psychosocial interactions of
oncology nurses identified coping methods that these nurses used with dying patients when
20
dealing with stressful situations. It also gave evidence of the effectiveness of programs that
would benefit both patients and nurses.
Lyckholm (2001) presented possible activities that might be used for coping such as short
breaks, extended rest time away from work, sleep, exercise, hobbies, meditation, relaxation,
reflection, learning to grieve well, and the development of a supportive environment to decrease
burnout. These measures are important for all nurses to use but do not focus on specific grief
tasks that would enable nurses to cope with the loss of their patients.
Social support of oncology nurses was recommended by Medland et al. (2004) as a goal
for health care agencies. The use of support groups would contribute to enhanced quality of care,
and cost effectiveness. Since stress and burnout of nursing staff can lead to a high turnover of
nurses, the use of support groups may alleviate this problem and reduce costs. Similarly, other
studies have found that on-site counseling programs are not only cost effective, but a valuable
tool in achieving retention of nursing staff (Guillaume & McMillan, 2002; Toran, 2003).
Luquette (2005) suggested on-site counseling programs that incorporated confidential
services on an individual or group basis would be beneficial for retention of nursing staff. These
types of services can address issues such as work-related stress, compassion fatigue, and
adjustment to the workplace. Although telephone consultations have gained in popularity due to
their convenience, participants do not have the benefit of interpersonal interaction that occurs in
a group session. In addition, group counseling can be the most effective and efficient way to
deliver services in a healthcare setting when issues addressed affect many staff members. It is
evident that support programs can help to reduce stress and prevent burn out for nurses. Evidence
shows that these programs provided the opportunity for nurses to deal with their grief and losses
by becoming emotionally equipped to reduce the stress in their professional role. If support
21
programs are not available in an agency, nurses must deal with their grief alone. How are nurses
dealing with their grief over the loss of patients if support is not available?
Summary
Nurses who work in oncology units experience the death of patients on a continuing
basis. The frequent loss of patients is stressful and nurses need to find ways to grieve the losses.
The sense of loss and associated grief is amplified by the fact that oncology patients often return
to the unit multiple times during the course of their illness. This leads to the development of a
close bond and trust between the patients, their families, and the nurses. Literature suggests that
nurses find support by sharing their common concerns with their peers. Establishment of
supportive programs would assist oncology nurses to work through the issues related death and
dying. Health care agencies should establish planned programs on a consistent basis to provide
support to the nursing staff to enable them to work through the significant issues related to stress
and coping with deaths of patients.
22
CHAPTER THREE: METHODS
This qualitative descriptive study explored oncology nurses' experiences in coping with
the loss of their patients. The oncology nurses in this study provided written descriptions of their
individual personal grief experiences related to the frequent deaths of their patients in adult inpatient oncology settings. This chapter presents methodology including sample selection with
ethical considerations. The method used for data collection and analysis of common patterns of
responses will be incorporated in the discussion.
Researcher Credentials
The primary investigator is completing requirements for a Master of Science degree in
nursing with a concentration in nursing education. The primary investigator presently works as a
nurse educator in medical oncology and has eight years of experience in adult in-patient
oncology nursing. The primary investigator was responsible for all aspects of this study.
Purpose of the Study
The purpose of this study was to explore experiences of nurses who provided continuing
support to patients who are repeatedly admitted to oncology settings. Due to the length and
frequency of admissions, close relationships tend to develop among nurses, patients, and patient's
families. Since death is a frequent outcome for oncology patients, nurses must continually adapt
to the losses. The researcher's personal experiences prompted the concern to gain insight into
ways that nurses in these settings managed their grief with these frequent losses. The review of
23
the literature indicated that there was a need to conduct research specifically in the in-patient
adult oncology setting.
Research Design
The research design selected for this study was a descriptive qualitative study as defined
by Sandelowski (2000). She noted that it "involves a basic qualitative description" (p. 335)
which is a "valuable method by itself (p.335). She noted that with qualitative descriptive studies
participants have submitted written responses that the researcher has analyzed and interpreted.
Qualitative descriptive research is a "comprehensive summary of events in everyday terms of
those events" (Sandelowski, p. 336.). She also noted that with qualitative descriptive studies, the
researchers remain close to their data in order to get an accurate meaning of the events as
reported. Qualitative descriptive studies differ from the other types of qualitative research such
as phenomenology, grounded theory, and ethnographic studies although "they may, nevertheless
have hues, tones and textures from these approaches" (Sandelowski, p. 337.). A difference does
exist among the defined methods of qualitative research, but it is also evident that there are some
similarities among the various qualitative methods.
The process of death and dying is a personal experience, perceived differently by each
person who deals with it. This qualitative study captured the subjective experiences of individual
nurses who worked in oncology settings. Participants agreed to respond to a questionnaire that
sought a written narrative response of their experiences in coping with the death of patients in
their oncology work setting. Nursing staff also shared information on support measures provided
by institutions.
24
Sample Selection
The sample for the study was generated from a list of members of the Oncology Nursing
Society (ONS) that included a broad representation of nurses who worked in oncology settings.
The Oncology Nursing Society (ONS) gave permission to access the members of this
organization. The ONS reviewed and approved the questionnaire for the study, and they gave
permission to use the list of names and addresses of the members (Appendix B). Membership in
this organization was comprised of oncology nurses who worked in oncology settings across the
United States. The list was then limited to include names and addresses of nurses from the
Northeastern states including New York, Connecticut, Massachusetts, and Rhode Island. The
ONS created a list of 1000 names that included oncology nurses who practiced only in adult inpatient settings in Northeastern states.
The researcher selected every fifth individual from the list of the 1000 members of ONS.
Selection of 10 nurses from this group provided the total sample of oncology nurses for the
study. This was a type of systematic sampling method described by Burns and Grove (2004).
Wood and Ross-Kerr (2006) also described the use of this predetermined type of sampling as a
method to prevent bias with the selection of the sample. Systematic sampling was possible
because the researcher knew the total number of members in the population and the number of
nurses to be included in the sample. Selection of every fifth member continued until there was a
total sample of 10 participants. The researcher sent out additional mailings to obtain additional
ONS members until 10 questionnaires were returned.
Data Collection
The participants must have indicated that they had experienced death of patients in their
practice in order to participate in the study. They also had to indicate that they were involved in
25
some capacity in in-patient adult oncology settings. This was necessary in order for them to
reflect on their experiences.
The researcher sent a letter, questionnaire, and a self-addressed stamped return envelope
seeking permission and willingness to participate in the study to each individual nurse.
Information related to the ethical protection of the participants was also included (Appendix C).
The return of the questionnaire was used as an indication of agreement to participate in the study.
The questionnaire consisted of 2 parts (Appendix D): a section that requested
demographic information using multiple choice questions and a section consisting of 21 openended questions. The subjects were asked to designate the number of hours worked in the clinical
setting each week, and whether they currently practiced in an oncology setting. They were also
asked to indicate the specific setting for their practice and the number of years that they had
worked in an oncology setting. In addition, participants were asked to indicate the highest
educational degree they had attained.
The 21 open-ended questions that had been developed by the researcher based on
researcher's experience in oncology nursing and information obtained from the review of
literature. Prior to administration, the questionnaire was reviewed by several nurses who had
worked on an in-patient unit to assess the validity of questions. Overall, the nurses felt that the
questionaire elicited valuable reflection. However, based on their review, some questions were
changed or omitted prior to use in this study. Polit and Beck (2004) noted that the use of openended questions enables subjects to freely respond using their own terms. They also indicated
that open-ended questions provides an opportunity for the subject to be spontaneous with less
biased responses.
26
The nurses responded to the questions as a written narrative that reflected their own
individual experiences related to coping with the death of their patients in the oncology setting.
Streubert-Speziale & Carpenter (2003) noted that the use of the written narratives allows
participants to reflect on their experiences and review them before submission. This was
important to be certain that individuals had written and reviewed the narrative prior to returning
it to the researcher.
Ethical Considerations
The Institutional Review Board of Southern Connecticut State University approved the
study (Appendix A). The ONS gave permission by providing access to their data base list of
active members of the organization.
The researcher coded the questionnaire from number 1 to 10 so that there were no names
on any of the returned questionnaires. Subjects were also free to participate or decline from
participation by not returning the completed questionnaire. In addition, the letter indicated that
participants who returned the questionnaires could request to withdraw from the study at any
time by contacting the researcher. As required, study data will be retained by the researcher for
three and a half years and then it will be destroyed.
Data Analysis
The purpose of this study was to review the reflections of the nurses and to describe how
they viewed themselves in their nursing role with dying patients. Demographic data was gathered
to determine the general characteristics of the subjects in the study in terms of number of years
of experience in oncology, hours worked each week, and educational level.
Content analysis was used as the method of choice for this qualitative descriptive
research study. A preliminary review of the content of each of the questions was the initial step
27
in the process of analysis of the open-ended questionnaires. The researcher reflected on the
comments from each of the subjects and analyzed the responses for each of the 21 questions
comparing similarities and differences. Polit and Beck (2004) noted that the analysis of openended questionnaire is more difficult and requires a longer time to complete. The initial analysis
took over 2 months to complete. Comparison of each of the questions on the 10 questionnaires
resulted in evidence of key terms and notable thematic responses. The researcher grouped
responses to each of the 21 questions as a method for organizing data. Each of the responses to
each of the questions was read and re-read several times. The researcher then compiled and
transcribed the responses. With the responses listed from one to ten, the researcher analyzed the
data based on the similarities and differences. When analyzing the data, the researcher also
considered participant demographics, such as age and experience.
28
CHAPTER FOUR: RESULTS
The purpose of this descriptive qualitative study was to explore how nurses defined their
experiences in coping with the death of patients in the oncology setting. Death occurs often in
these settings, and as a result, nurses need to be able to cope with the frequent loss of their
patients. What activities and rituals do nurses use to provide supportive care to their patients?
How do they manage their grief related to the death of patients? Ten nurses who practiced in the
adult in-patient oncology provided data for this study.
Demographic Data
All 10 participants were nurses working in the adult in-patient oncology setting. Seven
nurses reported that they worked primarily in the in-patient oncology settings. The remaining
three participants indicated that they worked in both the in-patient and outpatient settings.
Hours Worked
The number of hours worked per week ranged from less than 24 hours to more than 40
hours per week. Two of the participants reported working less than 24 hours a week, while five
of the participants worked 24 - 40 hours a week. Three participants indicated they worked more
than 41 hours (see Table 1).
Years of Practice
Participants' years of practice experience in oncology nursing ranged from 1 to over 21
years. Four of the participants indicated that they had 1 to 5 years of experience in oncology.
29
Two of the participants had been in practice for 6 to 10 years, while three of the nurses had
reported 11 to 20 years of experience. The remaining nurse indicated she had practiced in
oncology nursing for over 21 years. Table 1 below illustrates participants' characteristics.
Table 1
Demographic Data of Participants
Participant
Current/Hours
Setting
Years of Exp.
Degree
1
2
3
4
5
6
7
8
9
10
<24
24-40
41+
41+
41+
24-40
24-40
24-40
24-40
<24
Adult In-Patient
Adult In-Patient
Adult In-Patient
Adult In/Out
Adult In/Out
Adult In-Patient
Adult In/Out
Adult In-Patient
Adult In-Patient
Adult In-Patient
11-20
6-10
21+
11-20
6-10
1-5
1-5
1-5
11-20
1-5
MSN
BSN
MSN
MSN
Diploma/AD
BSN
AD
BSN
MSN
BSN
Educational Preparation
Four of the participants were prepared at the master's level in nursing, while four of the
nurses reported having a bachelor's degree in nursing. One nurse reported that she had a diploma
in nursing and the remaining participant reported having an associate degree in nursing. Three of
the nurses, who reportedly had worked in oncology for the longest time, were all prepared at the
master's level in nursing.
Analysis of Data
The researcher analyzed the data based on the written responses from the 10 subjects in
the study. Common thematic responses were evident with repeated review of the data from the
open-ended questionnaires. The participants responded in writing to the questions by describing
30
the ways that they managed to cope with the continuing loss of their patients. Given the study
design and sample size, the results relate only to the oncology nurses in this study and cannot
generalize to the total population of oncology nurses.
Experience with Frequency of Death
Participants indicated how often they had experienced the death of patients in their
nursing practice. The most common response provided by three participants was "very often".
The other nurses used qualitative descriptors such as "often", "frequently", and "regularly".
Some participants included narrative comments indicating that they experienced death from
several times a week to at least 1-3 per month. All of the participants experienced the death of
patients on a regular and frequent basis and described it in terms that had significance to them.
Activities and Rituals Employed
All of the participants indicated several activities they engaged in when patients died. The
most common activity described was discussing their feelings with other people. One of the
nurses commented she would talk about it with her colleagues, her spouse, or she would go to
the wake to follow up with family. Two of the nurses also indicated use of reflection as an
activity to help them cope with death. Comments included their thoughts about the patient, the
experiences with the patient, and of the impact of death on that patient. One nurse wrote, "I think
about the patient feeling better and this is the end of suffering." This nurse indicated that she had
1-5 years of experience. Another nurse with the similar length of experience described that her
knowledge actually helped her to cope. She noted that "not having cure in mind, understanding
the death and dying process and [to] have the belief that you are making the best health
possibilities despite prognosis including spiritual, emotions, physical being."
31
Another activity the nurses described related to individual religious beliefs. Two of the
nurses considered spiritual support as important for them in that they attended church and prayed
which helped them to cope with the losses of patients in their professional role. One other nurse,
on the other hand, commented that distancing herself was helpful to her. "I just leave my feelings
about the situation at work, it is part of the job and I expect it. I try to distance myself from the
emotional aspect." This participant did not indicate any ritual, but explained that she left her
emotions related to the death of the patient at work. This helped her to manage the emotional
aspect of coping. The conscious act of not experiencing emotions outside of work seemed to be a
useful ritual for this participant. Two of the nurses initially indicated that they did not participate
in any activities or rituals. They did provide comments indicating that they were involved in
some kind of activity at the time of the death of their patients. One of the nurses wrote, "I do
usually participate in post-mortem care." This is a normal physical preparation of the body after
death. The other nurse responded "none" and then described, "I guess I talk to my family and
fellow nurses." Initially these nurses indicated that they did not think that they performed any
rituals, but with further reflection on it they did identify some type of activities or rituals that
were helpful to them.
The responses of the nurses described a range of activities that they used to cope with the
death of patients. The most consistent activities included reflection and sharing thoughts with
colleagues or family. Other comments from nurses indicated a need to use religious beliefs as a
way to understand and deal with the frequent dying and death of patients, which is part of life.
Nurses indicated they used their professional experience in coping with death and applied it to
their personal life experiences.
32
Impact of Presence with Death
The nurses described how they were able to cope with being present at the time of death
of their patients. Four of the nurses noted that being present was better, or that they preferred it
because it affected their coping in a positive way. One of these four subjects stated that it is,
"better to be present, [being present] facilitates better closure." Also, another one of these nurses
explained that when she is present, she could ensure that the death was peaceful. She stated, "[I]
prefer to be present to be sure in my mind all was peaceful and as painless as possible." Two of
the nurses described how their direct care for the patient at the time of death improved their
coping. Lastly, the fourth of these nurses indicated, "If I were there, I could have held his/her
hand." She also noted that no one wants to die alone. Being there for the patients provided an
opportunity for these nurses to respond to the stress with the patient's death. In the described
situations, the nurses had the opportunity to be supportive to the patient serving their role as the
nurse. One nurse noted, "It is easier for me if I am present, even though death is expected. When
you come in and find out someone has died, then it is always a jolt."
In contrast, four other participants indicated that being present at the time of death made
it more difficult for them to cope with the death because they focused on the patient and not on
themselves. At the time of death, the nursing role was to focus on providing care for the patient
experiencing the dying process and supporting the family surrounding the patient. One nurse
stated, "Being present is more difficult mainly because you usually have to support the family
members. Being present usually requires extra support from co-workers." One other nurse also
explained, "When you are present at the actual time of death of a patient your role is to
help/support others. When you are not present, you have the opportunity to think and internalize
33
the experience." It is evident that there were some variations in responses to this open-ended
question based on individual preferences and beliefs.
The nurses indicated the importance of their major role in providing care to patients and
family during the dying process. The experiences of being present or not being present affected
their coping experiences differently. Clearly, some nurses reflected on their own loss of the
patient, and were in need of support at the time of death. Their comments indicated that they
were having difficulty providing support to families at the time based on their own need. One
participant felt that being present at the time of death did not affect her coping with death. While
another participant stated often she heard about the deaths after and she did not have the
opportunity to compare. Overall, there were extreme variations in responses from the nurses.
Being present at the time of death affected each nurse differently based on a variety of reasons.
Memorable Experiences
All nurses, except one, wrote long descriptions of the most memorable experiences. One
nurse noted that no experience stood out as being memorable. This was interesting considering
the responses from the other nurses in the sample. This nurse indicated she had from 1-5 years of
experience in oncology nursing.
The experiences were special for each nurse for varying reasons, and certain themes
emerged from their comments. Four of the nurses noted that young patients especially created
the most memorable experiences. The death of younger patients was difficult to handle because,
as one participant noted "they are dying before their time." One nurse stated, "My most
memorable experience involved a young 25 year old female with inflammatory breast CA".
When the patient's disease brought her closer to death, she trusted the nurse and team to keep her
comfortable. Her "fight" attitude turned to peace. Her husband did not want to be present at her
34
actual death so the nurse helped him say good-bye. "He was comfortable leaving her under our
care. I was present."
Some nurses mentioned not only the patient, but also indicated the spouse and other
family members with their responses. These comments related to both the negative and positive
reactions of family members at the time of death of the patient. One nurse noted that she had a
difficult time with family members at the time of the death of the patient. Members of the family
were screaming, "Oh My God" and kneeling down at the time of the patient's death. "[It was] the
most difficult for me." Another nurse described a positive experience, when she noted that, there
had been so many deaths in her 20 years. "[The most] memorable experience involved death of a
young man whose wife very carefully prepared his body. She put soft music on, washed his body
and lovingly prepared him." It was evident that the nurse was deeply moved by the love the wife
had for her husband and the care she gave to him. In both of these situations, the nurses
considered the experiences to be the most memorable for them. The contrast between the two
separate responses is notable, and the question that comes to mind relates to the time element
that each nurse has spent working in an oncology setting. These nurses had indicated they had
between 6-20 years of experience in oncology. The memories they recalled remained quite vivid
for them.
Another participant noted the reaction of a family member in her response, "It was when
the patient's spouse said everything is done, no more chemo, no more pain." It was more like
resignation and acceptance of the dying process. The patient was no longer suffering. The nurse
interpreted this to mean that the spouse of the patient was at the end of grieving. One nurse wrote
a detailed story about the relationship between a husband and his wife. The nurse reflected how
moved she was by the devotion of the husband to his wife. The husband sent the nurse a gift that
35
he had presented to his wife and had left at her bedside while she was dying. The nurse was not
only impressed by the relationship that the husband had shared with his wife, but also by the
impact that she, as a nurse, had made upon the husband.
Nurses used a variety of common responses as a way of explaining the relationship
between patient and nurse. They included terms as "trust, primary nurse, and friend". They
recognized the relationships or bond that they had established with their patients. One of the
nurses described a relationship she developed with her patient, "A nurse who had leukemia and
was working on her MSN. I became very close to her. Before going to her wake I was angry at
what seemed a waste or loss in her death, but at her wake I thanked God that I had the chance to
meet her and become her friend." The relationship became one of true friendship. It is evident
that one could identify with someone in the same profession.
The nurses commented on the general physical deterioration of their patients along with
the nursing interventions involved at the time of death. In two specific situations, the nurses gave
detailed descriptions of this. A 34-year-old female, newly diagnosed with leukemia had a bone
marrow transplant. The patient had gained four times her weight from being on steroid therapy
that resulted in a weight gain that disfigured the patient. The patient was alert and oriented
almost to the end. The nurse noted that this woman did not want to die; this was apparently very
distressing to the nurse. One other nurse expressed concern for a patient who had experienced
five cardiac arrests with resuscitations and intubation. The family was very emotionally upset
which was stressful for the nurse who wrote, "It was horrible, I cannot shake the mental picture
of chest compressions from my mind." One other nurse was very upset with the death of her first
patient which she described as "Peaceful, but very sad."
36
This particular question elicited lengthy responses from the nurses. The significance of
the responses was clearly notable and it was important for them to write a meaningful narrative
with recall of the details of the occurrences. The age of patients also really impressed the nurses
so that the death of young patients was a deep concern for them. The relationships that had
developed between the nurses, patient and family members made a lasting memory for these
nurses. Other memorable experiences involved the physical state of the patients with their illness
including physical appearance of the patient and the strong reactions of family members at the
time of death of the patient.
Peaceful Death
All of the nurses in the study responded to this question by considering several nursing
care issues that addressed concerns for symptom management, and patient comfort with control
of pain. Eight of the nurses (80% of the sample) specifically used the terms "painless", "no pain",
or "pain controlled". These numbers indicated that all of the nurses considered the management
of pain a major concern for these dying patients in particular.
The significance of the presence of families was of concern to the nurses. The control of
symptoms for the dying patient along with the supportive presence of family makes a peaceful
death. Resolution of family related issues was also a great concern expressed by the nurses. One
nurse noted that when the dying person and the family know death is coming they talk together
and make amends. The survivors have to prepare to continue living without the person.
Nurses responded to an additional question related to peaceful death in terms of how the
impact of the peaceful death of patients affected nurses. Eight of the nurses used the terms,
"easier" or "better" when describing their own ability to cope after a peaceful death. One nurse
37
noted, "It's imminently easier to cope with a peaceful death." Another noted, "I feel better
because I know the patient and family are at peace."
Two of the nurses noted that by providing effective nursing interventions and improving
patient outcomes in a palliative setting it actually provided satisfaction for them in their nursing
role and function. All of the nurses described that they coped in a more positive way when they
felt that they had participated in providing a peaceful death.
Family-Nurse-Relationship/Contact and Service Attendance
The nurses indicated how often they remained in contact with family members of patients
who had died. Nurses primarily responded to this question indicating that they did not maintain
contact with families after the death of patients. It was interesting that one nurse did remain in
contact with family members. She described it as a "fortunate" experience, while other nurses
had not had or taken the opportunity to have such an experience. A nurse commented that the
lack of continued contact might be due to the family members' perspective or need for any
further interaction.
The nurses also described the relationship that they had with family members of the
patients who had died. All of the nurses responded to this question despite the fact that most of
them previously had reported that they rarely interacted with families after the patient had died.
Their response could be a matter of proper interpretation of the meaning of this question.
One other nurse indicated that she was involved in a bereavement group and did maintain
a close relationship with family members. She described these relationships, "If they come to
[the] bereavement group, we become very close and some others call or come back for a few
visits. Almost always there is a bond so that if I were to see a family member, we reconnect
emotionally right away." For this participant, the relationship with the family members
38
continued after caring for the patient, allowing both to continue the bereavement process
together.
Nurses described the relationship between nurses and family members as "supportive"
and indicated the great respect of the nurses for the family members. One nurse explained, "I'm
their support and guidance." One other nurse indicated she was part of a bereavement group and
indicated her involvement after the patient had died included attending services once every two
months.
The nurses indicated that they rarely attended funeral services, memorials, or family
events. Three of the participants simply stated they "never" attended these events. If they did
attend, it was only to one or two funeral services. A nurse indicated that she tried not to attend
services because it allowed her not to think about the death.
Sharing the Experience
All ten of the nurses noted that they shared their experiences with co-workers. Four of the
nurses reported that they shared their experience with their husband or family members. Another
nurse indicated that she shared her experiences with her minister, if the death was traumatic.
Nurses described praying and having faith as helpful in coping with the death of patients. Three
of the nurses identified family and children of the patient who had died as people with whom
they share their experiences.
Coping
The nurses also described specifically how co-workers helped them to cope with the
death of patients. The majority often participants (N=9) gave descriptions of how their coworkers supported them with deaths of patients. The common terms related to communication
included talk, share, vent, listen, and support among nurses and colleagues. The nurses indicated
39
that these actions assisted them in coping with their dying patients. One nurse noted that sharing
her experience allowed her to verbalize fears or feelings related to loss and this sharing helps her
to cope with the death of patients.
The nurses described how they had changed in their ability to cope with the deaths of
their patients. The terms used to describe how they felt they have learned to cope were, "it is
easier" or "better". A nurse who had over 21 years of experience indicated that the process for
her had not changed, and one other nurse with 11-20 years of experience noted, "It has gotten
healthier." One nurse wrote an interesting comment, "I am leery to become close to those who I
know will die, but as I have worked in oncology I am having an easier time opening up to the
terminally ill patient and being honest about outcomes." One of the nurses admitted that when
she first began practicing in oncology settings 20 years ago, she had a tendency to cry when a
patient was dying. She noted, "This is totally different now. I still feel the emotions, but I can
support patients and families."
Nurses noted that dealing with death is just an expected part of their job. Their comments
reiterated this attitude of the expectations in working with dying patients. One nurse expressed
this change by appropriately noting, "My overall goal has changed. You cannot save all
patients." Another nurse's comment indicated, "I look at death as part of my job, I expected it,
and I have learned how to participate in the dying process without becoming emotionally
attached to the moment or the family or the patient. My way of coping has not changed much
other than being more comfortable with it."
Coping Resources
Nurses discussed the available resources at their agency that assisted them in coping with
patients' deaths. Five of the nurses indicated the availability of spiritual services for the staff,
40
which included pastoral care, chaplains, or ministers. Responses indicated that few specific
programs or resources were available for the nurses in this sample. The main informal sources
they described were their co-workers, peers, and doctors. These oncology nurses in the sample
worked in various states and different oncology settings or agencies. Comments indicated that
problems existed with establishing supportive programs. Visits to nurses by spiritual
representatives were described as infrequent.
Nurses then described resources that would be helpful to them in coping with the death of
patients. Four of the nurses indicated that scheduled staff meetings might provide the needed
support for the nurses. One of these nurses noted that meetings would be helpful, but the greatest
barrier was time to set up meetings.
Three other nurses had no suggestions for supporting each other. They felt that death is a
very personal thing and each nurse deals with it differently. The role of the nurses involved
supporting the patient and family at this significant time, and their attention and interest focused
on meeting those needs.
Surviving patients
The nurses were asked to comment on how often they saw patients they had cared for
who were either in remission or cured. All but one of the nurses indicated that they did not see
the patients who either were cured or in remission regularly. One nurse who worked only in the
in-patient setting stated that she saw these patients very often. It was unclear from the data how
she saw these patients. Two nurses who worked in both the in-patient and outpatient settings
noted that they saw these patients all the time or on a weekly basis. These responses indicated
that the nurses who worked in both these settings had different experiences from those nurses
who worked only with the in-patient population.
41
The nurses' responses indicated that seeing surviving patients was helpful to them in
coping with the death of others. Nine nurses reported that they did not see patients who were
cured or in remission on a regular basis. However, seven of the nurses reported that seeing
patients who survived was a positive and uplifting experience. It was unclear how despite nine
nurses reporting that they rarely saw surviving patients could describe seeing them as a positive
experience. Six of these nurses worked in the in-patient setting only. The nurses used descriptive
words such as beneficial, inspiring, positive, and hope to describe these experiences. Some of the
examples of statements included, "What a joy and hope to see that my interventions and
administration of chemo has mattered", and "It is so uplifting to see survivors and it provides
some balance." One nurse stated, "It makes the ordeal of intensive chemotherapy side effects
worthwhile, it makes you understand that some patients die, but there are some that go on to
have happy positive lives."
These responses indicated that knowing patients who survived enabled these nurses to
consider the positive benefits of their own role in providing nursing support to their former
patients. Although, at the time of care the experience may have not been positive, for survivors
the experience was ultimately worth it.
The other three nurses felt that having contact with surviving patients made no difference
in their coping process. Two of these three nurses worked in the outpatient setting. They did not
understand the relationship, or they felt that seeing surviving patients might have a negative
impact related to coping. One nurse stated, "I don't relate these two things." For this nurse,
seeing survivors did not affect her ability to cope. One other nurse described how this experience
could negatively influence her coping, "sometimes seeing surviving patients can make you feel
more sadness for those who have died because ultimately you want all patients to survive."
42
It is possible that the nurses did not see the relevance or relate seeing surviving patients with
their ability to cope in their nursing role due to the majority not seeing these patients on a regular
basis.
Stress
Determining the impact of a patient's death on the nurse is very subjective. Seven of the
nurses indicated that the impact of a patient's death was very stressful. Other nurses reported that
it was less stressful. The three nurses described that only at times was it stressful. For example,
one nurse described the stress related to working with a patient who had bone marrow
transplantation. In this situation, the patients' frequent re-admission and long lengths of stay had
resulted in the nurse describing the patient as part of "our family." The closer the nurse felt to
her patient, the higher level of stress she experienced with their death.
Two of these nurses had different perspectives on ways to cope with stress. One nurse
indicated that she did not even think about stress while the other nurse indicated, "Except for the
occasional exceptional care, death is usually quiet calm and peaceful on our unit." This nurse had
a master's level preparation and functioned in both an administrative and clinical role in her
particular setting. She indicated that she did not deal with dying patients constantly.
Nurse Retention
Nurses responded to the question of whether dealing with frequent deaths made them
consider leaving oncology nursing. Eight of the nurses responded in very strong terms that they
would not even consider leaving oncology nursing practice. One nurse, who had worked in
oncology for 6-10 years, indicated that she had not really thought about leaving the field, but
over these several years of nursing practice, she had learned how to cope better with patients'
deaths. One other nurse in the sample indicated that she had worked in the oncology setting for a
43
range of 1-5 years. She commented that she possibly could consider leaving oncology nursing
because of the impact of dealing with death.
The nurses described the reasons that they continued to work in oncology settings in spite
of the frequent exposure to the death of patients. They indicated that their practice was both
rewarding and a privilege that provided them with satisfaction with their nursing role. The
responses indicated that their experiences were worthwhile even with the frequent occurrence of
death.
One nurse, who had strong religious beliefs explained that practicing in oncology has had
a strong personal impact on her life. It has helped her to appreciate the important parts of life and
has made her calm, appreciative, and sensitive to others. One nurse wrote that she loved her team
of co-workers. Her overall experience in dealing with frequent death has not affected her desire
to remain in the oncology setting.
Resilience
The nurses indicated how they felt they had developed resilience to death. They
responded to this question with contrasting responses. Four of the nurses felt they had developed
resilience to death in some way. One nurse stated, "I have developed an acceptance of death with
the repeated exposure to patient death. I suppose I have reached some level of resilience."
Another nurse explained that even though she felt great sadness at the death of some patients, she
felt she had developed some resilience. She continued to explain that dealing with death tends to
make an individual desensitized to it.
Two other nurses felt they had developed resilience to death. It is interesting to note that
three of the nurses who felt that they had developed resilience only had 1-5 years of experience
in oncology nursing. They had been in nursing for the least amount of time and this might
44
account for the responses. An older person may be more apt to consider his/her own mortality
based on life experience and age as noted by one nurse who reported 11-20 years of nursing and
oncology experience. One participant did not directly respond that she had developed resilience
to death, but noted she had developed acceptance to death. She explained this with her response,
"I accept death as part of life but I do not understand it, logically I know the need for death."
The other five nurses did not feel that they had developed resilience to death. They did
respond to this question. One of them felt that each death is significant, while another nurse
explained that her experiences with dying patients and their families have made her realize the
enormous impact of death for the family member. One other nurse noted that every time it is
different and never easy especially if you knew the patient well.
It is evident that there were variations of responses to the concept of developing
resilience toward death. The nurses who felt they had developed resilience explained how they
had developed acceptance of death; they continued to experience emotion with the loss. The
nurses who did not feel that they had developed resilience noted that every death is significant
and the deaths continue to have an effect on them.
45
CHAPTER FIVE: DISCUSSION AND IMPLICATIONS FOR PRACTICE
Oncology nurses experience death frequently as they care for patients diagnosed with
cancer. Despite the constant exposure to death, oncology nurses continue to work in the
specialty. The purpose of this qualitative descriptive study was to explore the nurses' experiences
in coping with the loss of their patients in the oncology settings. The outcome of this study
provided descriptive qualitative data from a sample of 10 nurses who were active members in the
Oncology Nursing Society. The findings of the study revealed similarities and differences among
nurses' responses related to how they coped with the continual loss of their patients. The
information in the study provided qualitative evidence that may be useful toward establishing
support programs to assist nurses through stressful times in their nursing practice.
Findings from this present study cannot be generalized to the whole population of nurses
who worked in oncology settings. However, the results contribute to the findings from similar
studies related to oncology nurses in similar circumstances. Findings provide additional
knowledge and insight into understanding the perspective of nurses who continually work with
dying patients.
The findings of this research study provided qualitative descriptive evidence that nurses
who worked in oncology settings across several states, encounter frequent stressful situations
with respect to dying patients. Nurses indicated that they shared their concerns and issues with
46
their peers as a way to cope with the frequent death of patients. These nurses had limited time to
discuss, talk and vent with co-workers while caring for patients.
The nurses indicated that there were few or no support resources available for them in
their work setting. Nursing leaders need to take the initiative to plan and implement supportive
programs for nurses who work in oncology units in their organization. The programs would be
instrumental in providing the needed support for nurses in their stressful environment. This
would also be useful in promoting retention of the nursing staff in these clinical units. It is
notable, however, that the nurses indicated that they intended to continue working in an oncology
setting.
The literature has indicated the usefulness of planned support programs to meet the needs
of nurses in particular (Fitzpatrick et al., 2001). This is especially important for oncology nurses.
Establishment of these types of supportive programs are needed as an essential component for
health care agencies. These programs will decrease stress and provide support to the nurses
ability to cope with the frequent deaths of patients as well as retention of nurses in oncology
settings.
Regularly scheduled planned programs will allow nurses to discuss their concerns and
support for each other. Egan and Arnold (2003) studied strategies used by nurses in hospice
settings to determine coping strategies with frequent death of patients. They suggested that
having support through programs for nurses had significance for nurses. Dealing with death is a
very personal experience and responding to individual needs enabled positive outcomes related
to nurse coping. It is important for nurses to have the opportunity to express their concerns and
needs when caring for dying patients. Providing support related to end-of-life care and assisting
47
nurses to provide effective care for dying patients will enable nurses to provide symptom
management and support patients toward a peaceful death.
The nurses who participated in this study identified experiencing frequent deaths had
made a significant impact on them in their practice. Lewis (1999) attributed nurse burnout in the
oncology setting to the frequent loss of patients. This issue related to burnout had been
determined at the outset of this study. The demographic data of the sample indicated that several
of the nurses had worked in oncology settings from 10 to 20 years. These particular nurses
indicated their commitment to remain in the oncology setting based on their length of stay up to
this time. It is evident that they must have developed some measures to cope with frequent
deaths of patients and view this as an expectation of their professional role.
Based on the overwhelmingly consistent responses among all nurses in the sample,
nurses share and discuss their experiences with others after a patient died. Other study findings
also have indicated that sharing with others was a common method that nurses used to deal with
work related issues (Payne, Dean, & Kalus, 1998). Sharing concerns with others has enabled the
nurses to handle their stress.
Another theme was the use of prayer and faith to help them cope with the death of a
patient. This is consistent with a recent study that also concluded that nurses used their own
religious and spiritual beliefs when evaluating the end-of-life care they have given (Mitchell et
al., 2006). The nurses worked together as a team and all were experiencing similar losses, so that
they could really relate to their peers as the losses occurred. Egan and Arnold (2003) noted that
prayer provided a chance for enhance spiritual growth in nursing staff.
48
Facilitating activities that allow for peer support and observation of spiritual beliefs will
positively influence nurse coping. Acknowledging that staff activities should be permitted and
encouraged will enable nurses to access the most recognized behavior of the coping process.
Based on the responses, being present at the time of death is difficult for some nurses in
coping with the actual dying process. Egan and Arnold (2003) also noted that nurses exposed to
frequent deaths find it more difficult with the resolution of grief from one death to another.
Although, some nurses find it comforting to be present, nurses have clearly two different points
of view on this subject. However, it is unclear whether nurses are allowed by peers to make the
decision to not be present at the time of death. For example, unit culture might influence a nurse
to take a patient at the time of death despite a nurse's resistance. In practice, nurses need to
support each other with their desire to not be present. An example of this is a primary nurse who
may desire to stop caring for a long-term patient as he/she begins actively dying.
The most memorable experiences related to the deaths of young patients, close nursepatient-relationships, or the reactions of the family members. Ablett and Jones (2007) indicated
the same finding with a sample of nurses who worked in palliative care units. These nurses also
noted that when they cared for a patient over a long period a friendship developed between the
nurse and the patient. Comments indicated that these events were stressful for them. One nurse
described that she was angry that the patient died. This indicated that she experienced the second
stage of anger as described by Kubler-Ross (1969). Other studies have indicated that when
nurses developed a close relationship with their patients, they found that it was a very stressful
experience when their patients died (Hinds et al., 1994; Kushnir, et al., 1997). In situations,
where patients are young or well known to unit staff, it is extremely imperative that timely
support be given to nurses. It is important that nursing leadership be aware of these situations
49
and types of deaths. Recognizing increased nursing stress and difficulty to cope at the time of
these deaths is significant impacting long-term outcomes.
The nurses who participated in the study almost universally agreed that a peaceful death
was one without pain or other distressing symptoms. One of the main concerns of the nurses was
that they continually assessed the comfort of the patient as an essential component in their
supportive care for their dying patients. This allowed the nurses to feel that they had provided
care that enabled a peaceful death. The nurses indicated their commitment to improving the
quality of end-of-life care of their patients. A study by Ablett and Jones (2007) also noted that
palliative care nurses recognized that that a "good death" was important for patients and family
(p.736).
The nurses in the study noted that they had a sense of accomplishment when they
promoted what they perceived to be a peaceful death; it enhanced their ability to cope with the
death more effectively. Rittman et al. (1997) noted that nurses who felt that they assisted patients
to achieve a good death began their bereavement process while caring for the dying patient. It
would indicate in the present study that some of the nurses were able to move through the stages
of grief as defined by Kubler-Ross (1969). Educating nurses on aspects of palliative care, such
as pain management, will facilitate their ability to achieve their perceived vision of a peaceful
death. Providing resources like palliative care nurses and doctors will also facilitate this process.
Nurses who worked in the in-patient setting indicated that they had limited contact with
surviving family members after the patients died. Those who had the opportunity to interact with
family members described these in a positive way. Consistent with a previous study, nurses in
this study noted that calling family members of a patient who died was a positive experience for
the nurses (Kaunonen, Aalto, Tarkka, & Paunonen, 2000).
50
Nurses who worked in the in-patient units did not have the opportunity to participate in
the support programs for family members. Scheick (2002) noted that support programs are
underused, but nurses could provide a viable treatment role in these types of programs in all
specialty areas. Oncology nurses could be facilitators and leaders with the bereavement programs
for patients' families. Those nurses who described that they had experiences working with
support groups perceived these interactions to be beneficial for them as well as for family
members. One of the nurses in the sample worked in both in-patient and outpatient settings. She
was a facilitator in the outpatient setting bereavement support group and described that these
support programs for family members were useful and a very rewarding experience. Facilitating
and creating programs that allow nurses to be involved in these activities can help their coping
experience. It is important the nursing leadership support these activities will take them away
from direct patient care.
A positive experience that nurses described was to attend funeral services. It somehow
added a sense of closure for them. The decision to attend services varied, it was a matter of their
individual choice. However, it is necessary to determine appropriate guidelines and allowances
for staff that are compelled to participate in funeral services. Attending these services might
affect work schedules and time-off. Due to this, nursing administration should evaluate whether
or not it is possible and under what circumstances. It is important to supporting nurses who wish
to attend.
It was evident that all of the nurses found value in sharing their experiences with coworkers after a patient had died. All of the nurses in the study noted that talking, crying, sharing
emotions and reflection on the death of patients with co-workers was an important way for them
to cope. This finding is consistent with the study conducted by Jack (2000) that concluded the
51
most used and effective method of coping was the "supportant" coping style. Kulbe (2001) found
that hospice nurses valued informal discussions with peers as a positive support measure. The
development of grief teams made up of nurses, chaplains, and others was effective in decreasing
compassion fatigue and distress (Brosche, 2007). An important suggestion would be to establish
a formal grief team for these nurses in their respective agencies. A carefully planned program
would provide the support for all nurses in dealing with frequent death of patients.
Some of the nurses responded that death was an expected aspect of their job or life. Boyle
(2000) concluded that nurses who described experiencing death as "part of their job" are at risk
for ignoring their feelings. Boyle also indicated that oncology nurses may ignore their grief
related to the death of patients. Newer nurses, with less experience working with oncology
patients, have had less time to develop their coping skills in dealing with the death of patients.
The more experienced nurses in these settings need to recognize that if they wish to retain newer
nurses on these units, they need to provide an ongoing level of support. A mentor program
where experienced nurses facilitate the development of coping skills could help newer nurses
with this process.
Few supportive resources were available for the nurses in the oncology settings as
indicated by their comments in the study. This type of support would have been helpful for
nurses to cope with the death of their patients. Some nurses indicated there was a need for
support personnel such as social workers, chaplains, and ministers. There were planned
bereavement services for the families of patients who had died, but there were limited or no
programs for the nurses.
Fitzpatrick, Bunevich, and Jones (2001) found that a day away for nurses that included
social work and pastoral care staff was a beneficial support measure for staff. The participants in
52
this study explained that the resources provided were not on a consistent basis. However, when
provided these resources were perceived as favorable. If planned on a regular basis a program
such as this would be more helpful for the nurses in their practice.
Brosche (2007) discussed developing grief teams within health care systems. The team
would be available to provide support and comfort to nurses after the death of a patient.
Establishing this type of supportive service for oncology nurses would be helpful in meeting the
needs of nurses in the present study. It would require a commitment on the part of the health care
agency to plan for and implement this type of a project for the nurses.
Several studies have indicated that stress related to the death of patients is an
individualized experience (Hinds et al. 1994; Lees & Ellis, 1990; Papadatou et al., 2002). In this
present study, the ten participants evaluated the impact of their own stress in very different ways.
The responses of the nurses varied based on their own individual perceptions and experiences.
Six of the ten nurses reported they had worked in oncology from 6-21 years. The length of time
that they had worked in the oncology setting could have influenced their ability to cope. They
indicated that each death was stressful, but they had developed measures to cope by sharing their
concerns with the staff in the oncology setting. Ablett and Jones (2007) found that nurses
characteristically shared their concerns related to stress, and coping with the nursing staff on
their clinical units. This present study included similar recurring responses used by the nurses in
the sample for coping with the ongoing stresses in the oncology setting. It is important that
support groups are developed to facilitate sharing and peer counseling among nurses. It is
particularly important to provide these measures for newer nurses. A mentor program could be
established where experienced nurses share their coping strategies with younger less experienced
nurses.
53
All but one of the nurses indicated that they planned to remain in oncology. They
indicated that the frequency of death in the setting would not have an impact on their decision to
remain or leave the oncology specialty. The nurse who indicated that she would leave the
specialty had only been in oncology for 1-5 years. She may have needed additional support in
developing her coping skills. A study by Luquette (2005) found that on-site-counseling reduced
workplace stress and compassion fatigue while increasing nurse retention. These nurses reported
that the main reason for staying in the specialty, despite the frequency of death, was the
rewarding experiences that they had as oncology nurses. Consistent with findings by Luquette,
the oncology nurses in this study indicated continued commitment to practice in oncology
settings. Again, it is imperative to support newer nurses. The development of programs that
discuss the rewarding experiences that they have as nurses may serve as a positive intervention
to retain nurses in the specialty.
Half of the nurses in the sample noted that they felt they had developed a sense of
resilience related to death, while the remainder of the nurses indicated that they felt they had not
yet developed resilience. The concept of resilience could be comparable to the fifth stage as
described by Kubler-Ross's with acceptance of the dying and death. This fifth stage of
acceptance occurs when the individual has reached the point and resolved the loss of the person
who has died. The nurses who considered themselves resilient had been able to cope with the
losses in their professional role. Finally, supporting new oncology nurses in the first five years
of practice in the development of their coping skills will facilitate them to stay in oncology
nursing and effectively cope with the unavoidable reality of frequent deaths.
54
Limitations of the Study
There are limitations to this descriptive qualitative research study. The sampling
technique of using a predetermined amount of participants did not allow for adequate data
saturation. Data saturation only occurs when there is a repetition of discovered information and
confirmation of previously selected data (Morse, 1994). In this sample, there was repetition of
data among participants. However, repetition did not affect ongoing participant selection. A
sample size of 10 was originally set based on the volume of questions and potential length of
responses.
The intention was to use a purposeful sample in that participants only included adult
inpatient oncology nurses. Purposeful sampling selects individuals based on their particular
knowledge of a phenomenon (Streubert- Speziale & Carpenter, 2003). Although all participants
worked in the inpatient setting, a systematic approach determined who was sent a questionnaire
out of the 1000 nurses. In addition, despite sample selection from 1000 members of the ONS
who practiced in several states and across various types of organizations provided a broad pool
of participants other oncology nurses who are not members of ONS may differ in responses.
Additionally, subjects were all female. Male nurses might have responded differently to the
questionnaire from their perspective.
There was some variation in the level of educational preparation of the nurses in the
sample. The differences in knowledge and experience could have skewed the responses based on
the role and function of the nurses. It was unclear whether some nurses held leadership positions
that limited direct care. Those participants who did not respond to the study might have
provided different responses based on their individual experience in general and in the oncology
setting.
55
The instrument was an open-ended questionnaire that the researcher developed.
Although, oncology nurses reviewed the instrument, the length of the questionnaire could have
decreased the number of willing participants. In addition, responses to individual questions
might have been limited because of the limited space provided on the instrument.
The nurses' written responses to the questionnaire was by self-report which presented a
chance for bias on the part of the subjects in the study. Burns and Grove (2004) indicated that
respondents may not have had adequate knowledge or understanding based on the questions
posed. The individual subject could make a guess and then respond with inaccuracy or bias.
Another limitation was that given the data collection method, the researcher was not able to
clarify and verify the responses made by the subjects.
The rigor of the study can be determined by evaluating credibility, dependability,
confirmability, and transferability (Lincoln & Guba, 1985). The researcher did not contact
participants to validate their responses limiting credibility and dependability. Determining
whether or not the findings are transferable depend on the users of the findings and not the
researcher (Sandelowski, 1986). Therefore, others must evaluate transferability in similar
situations. Conducting an additional research and applying findings in practice may provide
evidence of transferability.
Recommendations for Future Research
Further study needs to take place to determine effective support strategies for nurses who
work in oncology settings. Based on results from this study, nurses need support to provide
quality of end- of- life care for dying patients. Families of terminally ill patients also need
support. Additional studies could add to the existing knowledge regarding support. The use of a
larger sample and a validated instrument would also provide stronger support for findings. The
56
inclusion of male nurses would also be important to determine if gender differences exist in
terms of coping. Finally, studies could be conducted to determine the extent and the effectiveness
of established support groups for oncology nurses.
57
APPENDIX A
|m|f Southern Connecticut
S!II!! State University
sc
501 Crescent Street
New Haven, CT 06515 -1355
Human Research Protection Program
Institutional Review Board
Dr. Frank E. Sansone
1RB Chairperson
Voice: (203) 392-5968
FAX: 1203) 392-5968
Email: Sansonef1@southernct.edu
Date:
12/19/07
Attn:
Ms. Elizabeth Blasiak
48 Oberlin Road
Hamden, CT 06514
Re: Protocol Review
Protocol Title: Death and the oncology nurse: A qualitative study to understand the adult in-patient oncology
nurse experience coping with the death of patients
Protocol Number: 07-190
Department: Nursing
Dear Ms. Blasiak,
Your protocol has been examined and is considered exempt from continuing IRB review. If during the conduct
of your research any changes occur related to participant risk, study design, confidentiality or consent if
applicable, data collection must cease and the IRB must be notified immediately so that appropriate review of
the changes may be accomplished.
If you have submitted a consent document and it has not been returned with this letter, it does not require IRB
date stamping. The use of your consent document in your research is strongly urged by the IRB.
Good luck with your research. If the IRB can be of any assistance please do not hesitate to contact me
directly. Please be sure to include your IRB number in any correspondence.
Sincerely,
Jy,
/ /
Jerome Haueetf,
Dr. VV, Jerome
HaoseJt, Chair, Dr. Frank Sar
Sansone, Associate Chair.
School of Graduate Studies
Voice: 203-392-5243, 203-392-5958, FAX 203-392-5221
Email: hauseltwl@southemct.edu. Sansonef 1 (Sisouthernct.edu.
(Revised 10/8/07)
A Campus of the Connecticut State University System
An Equal Opportunity University
58
APPENDIX B
^ONS
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November 16, 2007
Dear Elizabeth:
This letter confirms shipment of mailing labels, approved by the Oncology Nursing
Society for ONE TIME use, of its members per your request.
The following selection criteria were used:
ONS Members —In-patient Setting
In these states CT, RI, MA, and NY count to 1000 records.
Count: 1000
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The above amount will be charged to your Credit Card. I will email you a confirmation
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Pat Thomas
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Integrity • Innovation • Stewardship • Advocacy • Excellence • Inclusiveness
59
APPENDIX C
Elizabeth Blasiak
48 Oberlin Road
Hamden,CT 06514
Dear Participant,
My name is Elizabeth Blasiak. I am a graduate student at Southern Connecticut State
University. Completing a thesis is part of the requirement for my Master's Degree in Nursing.
You are being asked to participate in a qualitative research study which examines the adult inpatient oncology nurse's experiences in coping with death in patients. Before agreeing to be part
of this study, please read the following information.
In order to make an informed judgment on whether or not you wish to participate in this
study you should know about all aspects of the study its purpose, the procedures to be used and
any risks or benefits. If you decide to participate, please return your completed study
questionnaire in the pre-stamped envelope enclosed. Return of the questionnaire will indicate
your permission for the data to be included in the results of the research study. Completion of
the questionnaire should take about fifteen minutes.
This study was not designed to benefit you directly; however, what is learned from this
study may help to increase the understanding of how nurses cope with the death of patients and
what is needed to help them with coping.
60
There are no physical risks for participants of this study. There are no costs to you or
compensation for participating in this study. You may decide not to participate in this research
without any negative consequences for you. You may at any time and for any reason, decide to
withdraw from participation.
Any and all information obtained from you will be kept confidential and anonymous.
Your privacy will be protected at all times since no names are needed. On completion of the
study, questionnaires will be stored in a safe place in my keeping for three years. The data
collected however, may be used as part of publications and papers related to nurse's experiences
coping with the death of patients.
At any time, please feel free to contact me if you have questions about any aspect of this
study that is unclear to you. You may contact me by phone at (203) 389-1877 or by email at
Tippvwright@yahoo.com. If you have questions regarding your rights as a research participant
you may contact the SCSU Institutional Review Board at (203) 392-5958.
Thank You,
Elizabeth Blasiak, RN, BSN
61
APPENDIX D
Study Questionnaire
Please respond to questions in space provided. Please note questions are on thefrontand back of this page. If
additional space is needed, please use the back of the questionnaire and number your responses.
Demographic Questions:
1. Are you currently practicing in nursing? Yes
If yes, how many hours a week?
2. Do you currently practice in oncology?
No
24 hrs. or less
Yes
24-40 hrs.
41+ hrs.
No
If yes, what setting? (Check all that apply)
Pediatrics
Adult
In-patient
Out-Patient
Other
Please Specify:
3. How many years of experience do you have in oncology nursing?
1-5 yrs.
6-10 yrs.
11-20 yrs.
21+ yrs.
4. What is the highest degree you hold?
Diploma
AD
BSN
MSN
PHD
Study Questions:
1. How often do you experience the death of patients in your nursing practice?
2. What activities or rituals do you do to help you to cope with the death of patients you have
cared for?
62
3. Describe the difference in your coping process between being present and not being present
at the actual time of death of a patient you have cared for.
4. What is your most memorable experience in nursing that involved the death of a patient
whether you were present at the time of death or not?
5. What do the words Peaceful Death mean to you?
6. When a patient has a Peaceful Death how does this impact the way that you cope with
his/her death?
7. How often do you remain in contact with family members of patients who have died?
8. Describe your relationship with the family members of your patients who have died:
9. How often do you attend funeral services, memorials, or family events for your patients who
have died?
10. After a patient has died, with whom do you share this experience? (for example, co-workers, your
family members, social workers, counselors)
11. Describe how your co-workers help you cope with the death of patients:
63
12. Describe how your coping ability has changed over the course of your experience in
oncology nursing.
13. What resources are available to you at work that provides you with ways to help you cope
with the death of patients?
14. How helpful are these resources?
15. What resources do you think would be helpful for you in coping with the death of patients?
16. How often do you see patients that you have provided care for who are now in remission or
cured?
17. Explain how seeing these surviving patients impact your ability to cope with the death of
others.
18. Can you describe how stressful it is to deal with death at your work?
19. Has dealing with death made you think about leaving Oncology nursing?
20. Describe why you remain in the oncology setting despite your more frequent exposure to
death:
21. Would you say you have developed resilience to death?
Thank You
For Your Participation!
64
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69
Date: May 5, 2010
To:
Dr. Sandra Holley
From: Dr. Paul R. Petrie
Re: Elizabeth Catherine Blasiak's Thesis—2nd Review—Final
All specified revisions have been completed successfully, and the thesis is ready for
final approval.
THESIS LOG
Student's Name
•
•
•
fifo'toY, fJv,J*Un
^ & ^ i - v*m
Thesis Advisor is member of Graduate Faculty
IRB Approval Letter submitted (if appropriate)
IACUC Approval Letter submitted (if appropriate)
Proposal
•
Student is registered for Thesis Proposal
*Thesis Proposals only go to Dr. Jirsa*
*unless they are for Exercise Science*
Thesis Proposal Received from student:
tjtyfff
[Program expires.
Copy of Planned Program pulled from Records:
Proposal Sent to Reviewers:
Jirsa_
f^
McEachern
efitft^Gfy
McEachern
Petrie
*Exercise Science Thesis Proposals go to all Three Readers*
Received from Reviewers:
Jirsa
,
Petrier>r/~A\(/c7
Advisor notified of changes required (if any)*:_
Changes received*:
Returned to Reviewers:
Jirsa*
Petrie*
McEachern*
Received from Reviewers:
Jirsa*
Petrie*
McEachern*
Acceptance letter sent to studentpYVj\>\ CM
Final Thesis •
Student is registered for Thesis
Each Reviewer Must Receive a Copy of ALL Submitted Theses
Received from student with UMI form and cashiers check or money order:
te&VgUO
Petrie
Thesis Sent to Reviewers:
Received from Reviewers
Jirsa"
6fy>
Q \Q \ \ Q
. McEachern
McEachern^UTUO
Petri
McEachern
Advisor notified of changes required (if any)*:
Changes received*:
Returned to Reviewers:
Jirsa*
Petrie*
McEachern*
Received from Reviewers:
Jirsa*
Petrie*
McEachern*
Advisor notified of changes required (if any)*:.
Changes received*:
Changes Returned to Reviewers:
Jirsa*
, Petrie*
McEachern*
Changes Received from Reviewers:
Jirsa*
_, Petrie*
McEachern*
Acceptance letter sent to student:
* Optional
Revised 09-19-2007
THESIS RESUBMISSION
NOTE TO THE EDITORS
For the following thesis:
DEATH AND THE ONCOLOGY NURSE:
A QUALITATIVE STUDY TO UNDERSTAND
THE ADULT INPATIENT ONCOLOGY NURSE
EXPERIENCE COPING WITH THE DEATH
OF PATIENTS
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BY
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ELIZABETH CATHERINE BLASIAK
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1. The following references are included in the text:
Oehler and Davidson (1992) - is located on Page 13 (among other in-text citations)
Sandelowski (1986) - is located on Page 56
* The other two references were removed, due to previous deletions on prior revisions.
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