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ISSN: 2167-1168
Journal of Nursing & Care
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Experiences of Critical Care Nurses of Death and Dying in an Intensive Care Unit: A Phenomenological Study

Vasanthrie Naidoo1* and Sibiya MN2
1School of Nursing, Department of Medical and Surgical Nursing, Life College of Learning-KZN, South Africa
2School of Nursing, Faculty of Health Sciences, Durban University of Technology, South Africa
Corresponding Author : Vasanthrie Naidoo
School of Nursing, Department of Medical and Surgical Nursing
Life College of Learning-KZN, South Africa
Tel: + 0027 082 5191
E-mail: [email protected]
Received February 11, 2014; Accepted July 08, 2014; Published July 12, 2014
Citation: Naidoo V, Sibiya M (2014) Experiences of Critical Care Nurses of Death and Dying in an Intensive Care Unit: A Phenomenological Study. J Nurs Care 3:179. doi:10.4172/2167-1168.1000179
Copyright: © 2014 Naidoo V, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Background : Working in the intensive care unit can be traumatic for nursing personnel. Critical care nurses are faced with repeated exposure to death and dying as they are involved in caring for patients who are actively dying, have a terminal illness or face impending death. These nurses relate in different ways to the phenomena of death and dying within their nursing profession and their scope of practice. Critical care nurses often have a difficult time coping with the stress that comes with caring for those who are dying or relating to loved ones of those that are dying. Aim of the study : The aim of the study was to explore the critical care nurse’s experiences of death and dying. Methods : A qualitative, descriptive phenomenological research approach was used to guide the study. Approval to conduct the study was obtained from Durban University of Technology Faculty Research Committee, the eThekwini District Health Research Unit, and the Nursing Service Manager of the participating hospital. The study population comprised of nurses working in the Critical care unit of the participating hospital. Results : Findings of this study revealed that issues such as communication, multicultural diversity, education and coping mechanisms relating to caring for the critically ill and dying patient are essential in nursing education and practice. Conclusions : Critical care nurses need to have support networks in place, not only to assist in providing care, but also for their own emotional support and well-being.

Abstract

Background: Working in the intensive care unit can be traumatic for nursing personnel. Critical care nurses are faced with repeated exposure to death and dying as they are involved in caring for patients who are actively dying, have a terminal illness or face impending death. These nurses relate in different ways to the phenomena of death and dying within their nursing profession and their scope of practice. Critical care nurses often have a difficult time coping with the stress that comes with caring for those who are dying or relating to loved ones of those that are dying.

Aim of the study: The aim of the study was to explore the critical care nurse’s experiences of death and dying.

Methods: A qualitative, descriptive phenomenological research approach was used to guide the study. Approval to conduct the study was obtained from Durban University of Technology Faculty Research Committee, the eThekwini District Health Research Unit, and the Nursing Service Manager of the participating hospital. The study population comprised of nurses working in the Critical care unit of the participating hospital.

Results: Findings of this study revealed that issues such as communication, multicultural diversity, education and coping mechanisms relating to caring for the critically ill and dying patient are essential in nursing education and practice.

Conclusions: Critical care nurses need to have support networks in place, not only to assist in providing care, but also for their own emotional support and well-being.

Keywords

Critical Care Nurse; Death; Dying

Introduction and Background Information

According to Prompahakul, Nilmanat, and Kongsuwan it was noted that the most important aspect of nursing is caring and this is even more so in an intensive care unit (ICU) [1]. In a study done by Farrell, it was noted that critical care units of today are totally dedicated to saving lives by offering specialized disease and surgical management to many patients [2]. Not only must the critical care nurse be able to deliver high quality medical care skilfully, using all appropriate technologies, she must also be able to apply psychosocial and other holistic approaches when planning and delivering care [3]. According to Urden, Stacy and Lough critical care nurses fulfil speciality roles that require their clinical teaching, leadership, research and consultative abilities. According to Alspach [4], the scope of practice for acute and critical care nursing is defined by the dynamic interaction with the acutely and critically ill patient. Hay and Oken further argue that the psychological burdens placed on critical care nurses are extraordinary often the situation these nurses face on a regular basis can be likened to that of a soldier serving with a combat group [5]. Critical care nurses are continuously championing the needs of the critically ill patient, the family or significant others [6]. A study that was conducted by Dracup and Bryan-Brown, revealed that while much attention was focused on the critical care nurse’s role to assist others in the end-of-life or dying process, little attention was paid to the critical care nurse’s psychological, cultural, and spiritual well-being when dealing with death and dying or end-of-life issues [7].

Problem Statement

Even though a nurse can celebrate the positive effects that nursing care has on a patient, there may still be no closure when death, dying and despair are witnessed. Therefore, understanding critical care nurses’ experiences of death and dying can help the health care delivery system prepare and educate these nurses on issues relating to the needs of the dying or terminally ill patient and also teach them how to effectively deal with such issues

Aim of Study

The aim of this study was to explore the critical care nurse’s experiences with death and dying

Research Question

There was only one central research question that was posed to all the participants which guided the study, “What are the critical care nurses’ experiences of death and dying in an ICU?” Further probing questions were based on the responses from the central research question

Significance of Study

Understanding critical care nurses’ experiences of death and dying will help the health care delivery system prepare and educate nurses working in a critical care environment to the needs of the dying or terminally ill patient, as well as, assisting her in promoting quality end-of-life care in an ICU and how to deal effectively with the stress that these situations can cause.

Research Methodology

Research Design

A qualitative study using a descriptive phenomenological approach was used to guide the study. This type of approach was useful in describing the subjective experiences of the participants and in examining the beliefs and cultures that impact on the death and dying experiences of the subjects. A phenomenological paradigm is concerned with understanding human behaviour from the participant’s own frame of reference [8].

Study Setting

This study was conducted in the intensive care unit of a provincial hospital in the eThekwini District in the province of KwaZulu-Natal.

Sampling Process

A purposive sampling of all consenting professional nurses employed in the ICU of the participating hospital was done.

Data Collection

A qualitative data gathering method was employed. In-depth interviews were conducted with the use of an interview guide containing a demographic section as well as a central question to focus the discussion. The initial question that was asked was “What are the critical care nurses’ experiences of death and dying in an ICU?” Probing questions were then used to elicit more information.

Data Analysis

Giorgi’s four steps for data analysis were used to identify themes regarding experiences of death and dying. The goal was to keep the richness of the experience that each participant had with the patients that they cared for whilst exploring the descriptive meanings of such experiences, through identification of essential themes [9].

Trustworthiness

According to Polit and Beck, researchers want their findings to reflect the truth. Research that is inaccurate or holds a biased viewpoint cannot be of any benefit to nursing practice [10]. To enhance trustworthiness, the following four principles outlined by Guba’s strategies of credibility, transferability, dependability and confirmability were applied [11].

Ethical Consideration

Before commencement of the study, ethical clearance was obtained from the Durban University of Technology Faculty Research Committee (FHSEC039/10). Written consent was obtained from Nursing Service Manager of the participating hospital and eThekwini District Health Research Unit (HRKM189/10).All the participants made an informed, voluntary decision to participate in the study. The nature of the study, the right to refuse to participate, the risks as well as the benefits was fully described to them.

Research Findings

Participant’s Demographic Profile

The sample in the study comprised of four participants. Of the four participants, only 1(25%) was within the 20-25 years age group and 3(75%) fell into 38 years and above age group. With regards to the duration of the experience in ICU, 2(50%) had 4-7 years’ experience and the remaining 2(50%) had above eight years’ experience in ICU.

Critical care nurses’ thoughts about caring for a dying patient

It was apparent from the participants’ responses that the thoughts on death of an elderly or aged patient often crossed a critical care nurse’s mind. The concept of death being inevitable or real seemed to provide some measure of comfort to the nurse caring for the patient. When youngsters or children died, it becomes very sad and unmanageable at times for all staff in an ICU. The fact that it was a young person involved tends to make the whole situation highly emotional.

The age of the nurse caring for such a patient seemed to have a bearing on the way the nurse copes with the event. Younger nurses were found to be task orientated, and lacked the empathy, respect and psychosocial aspect of patient care. Older nurses were considered to be the most suitable candidates to deal with death and dying issues in the unit as they have more ‘humane attributes and qualities stemming from her life’s experiences as well as having sound technical and theoretical skills’.

Critical care nurses’ feelings about caring for a dying patient

The pain of watching a loved one die or caring for a loved one throughout the dying process can evoke feelings of despair, anger and even denial. Apart from playing the important role of being a patient advocate, the findings of this study revealed that the critical care nurse felt ethically responsible to do his or her best. Feelings of preparedness allowed the nurse to foresee or predict, using their nursing knowledge, the prognosis of a critically ill patient in their care. This helped them prepare themselves and others for what to expect.

Critical care nurses’ communication with dying patients

The findings of this study also revealed that the nurse who provided verbal and non-verbal communication with her patients, allowed her to become more in tune with the needs of the patient and their desires as they neared death. According to Lee, Anderson and Hill [12], sometimes culture plays a vital part in end-of- life decision-making. Responses from participants demonstrated that a critical care nurse needed to be aware of cultural attitudes, behaviours and traits of patients to enhance the caring component in critical care nursing.

Past experiences with death and dying and the impact it had on the critical care nurse

Michell also felt that repetitive exposure to resuscitative measures, end-of-life care needs, prolonging life by pharmacological and mechanical means results in psychological disorders such as post-traumatic stress disorder [13]. All the participants that were interviewed felt that a critical care nurse’s personal experiences with death and dying impacted on the way she communicated or related to her patients and their loved ones. Participants further stated that the knowledge and skills gained from their personal experiences of caring for a dying family member or any other person that they were associated with impacted on the way they communicated verbally and non-verbally with their patients and the family of their patients.

Support systems that enable the critical care nurse to cope with the trauma of death and dying

The findings of this study also showed that the ICU nurse experiences death in a critical care environment as a series of inter-relationships between patients, nurses, doctors and other members of the multidisciplinary team. This enabled them not only to support the dying patient or the patients’ family, but also to support each other in the face of grief. According to Kirchhoff and Beckstrand [14], the collaboration between ICU caregivers and member of the multidisciplinary team can result in timelier decisions regarding life-sustaining treatments. The table below provides a summary of themes and sub-themes identified in the study.

Discussion on the experiences of critical care nurses of death and dying in an intensive care unit

Acute grief following the death of a loved one or a patient in ICU is often intensely painful but diminishes over time as the loss becomes integrated into ongoing life and the general nursing routine [15]. Despite advances in the healthcare sector, the critical care nurse is not being sufficiently equipped with skills to deal with death and dying in their professional practice, especially if the nurse had little or no exposure dealing with death and dying issues. The knowledge and skills deficit of recently qualified ICU nurses dealing with death and dying issues was another feeling shared by all those interviewed.

There were also strong viewpoints regarding the active participation of the patient’s attending doctor in the end-of -life care of their patients, as well as in keeping the patient and relatives fully informed of the patient’s progress. Participants felt that the skills that had been acquired by them were learned through their personal and life’s experiences. It was also felt that other resources such as social workers, counsellors and designated grieving areas were needs that were still outstanding in the hospital ICU set-up.

Conclusion

Death takes an emotional toll on all persons caring for the dying and therefore, critical care nurses need to have support networks in place, not only to assist in providing care, but also for their own emotional wellbeing. Irrespective of religion, culture or race, spirituality plays a huge role when caring for the dying and provides a resource for coping with death and dying for participants in this study. A nurse’s age and level of maturity, as well as past experiences with dying and death plays a key role in providing care at end-of-life.

Recommendations

Nursing Education

Nursing as an academic discipline can, and should be concerned with the generation of new research about nursing practice, but this will remain meaningless if not integrated into learning and teaching especially in the clinical practice and setting. End-of-life or death education should be emphasised in undergraduate nursing curriculum and continue to be integrated to post-graduate or post basic nurse training. This should include skills specifically related to end-of-life care or dying in an ICU.

Institutional management and practice

Nursing as a profession needs to create a support network made up of the multidisciplinary team. Health care settings that have an ICU should have a separate grieving area that can facilitate the comfort needs of the family or loved ones of the deceased. Professional assistance and advice should be readily available to all ICU staff requiring debriefing from traumatic ICU events.

Policy development and implementation

All nursing staff allocated to work in an ICU environment should undergo an ICU orientation programme on the death and dying policies and protocols in an ICU. These policies should comply with the ethical and legal guidelines laid down by the laws of the country such as information on termination of life support, brain stem death testing and information of organ donation [16-18].

Further research

Further research is recommended to ascertain whether the present South African Diploma in Medical and Surgical Nursing-Critical Care nursing curriculum adequately addresses the issues of death and dying in an ICU. Research into the expectations of the grieving family and the dying patient from the ICU nurse will serve as useful sources for future research reference.

Strengths and Limitations

This study focused on a fundamental phenomenon (death and dying) in critical care nursing. Using a phenomenological research methodology, the researcher was unable to anticipate how the study was going to evolve. Much of the research design appeared to come about during the data collection and analysis process. Using this approach, helped the researcher examine the human experience based on the descriptions provided by the persons involved and what meanings these descriptions held for them for them alone.

References


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