Coping Mechanisms of Nurses Facing the Death of Pediatric ...€¦ · Coping Mechanisms of Nurses Facing the Death of Pediatric Patients A Literature Review Degree programme Degree

CopingMechanismsofNursesFacingtheDeathofPediatricPatientsALiteratureReviewLindaDindaMelinaEdwardsLilliMikkonenBachelor’sthesisMay2017Socialservices,HealthandSportDegreeProgrammeinNursing

Description

Author(s)Dinda,LindaEdwards,MelinaMikkonen,Lilli

TypeofpublicationBachelor’sthesis

DateMay2017Languageofpublication:English

Numberofpages42

Permissionforwebpubli-cation:x

TitleofpublicationCopingMechanismsofNursesFacingtheDeathofPediatricPatientsALiteratureReview

DegreeprogrammeDegreeProgrammeinNursing

Supervisor(s)Lehto,Siru&Sinivuo,RiikkaAssignedby-

Abstract

In2015,5.9millionchildrendiedworldwide.Althoughnursesfacethedeathofbothyoungandoldpatientsregularly,thedeathofapediatricpatientisoftenperceivedunfairandunexpected.Nursesstruggletodealwiththedeathofachildpatient,asithasphysical,psychological,emotionalandbehavioralimpactsonthem.Additionally,thismayhaveanegativeimpactontheoutcomesofcare.Yet,littleresearchexistsonthecopingmecha-nismsofnurses.Theaimofthisstudywastoexplorenurses’copingmechanismswhenfacingthedeathofapediatricpatient.Thepurposewastoprovideinformationonhowtoencounterthedeathofachildpatientandlearntoacknowledgetheideaofit.Thiswasintendedtopro-videinformationthatcouldbeusedineducatingfuturenursesandnursesworkinginvari-ousfields.Thestudywasimplementedasaliteraturereview.Thedatawassearchedusingthefol-lowingtwodatabases:CinahlandJYKDOK.Overall,elevenarticleswerechosentobere-viewed.Contentanalysiswasappliedintheanalysisofthedata.Threemaincategoriesweregenerated:socialsupport,institutionalsupportandpersonalcopingstrategies.Theapplicabilityoftheseresultsmightvaryaccordingtotheindividualandthenursingsettings.Therefore,theresultsindicatedtheneedforfurtherresearchtodeterminewhatkindsofcopingmechanismswouldbebestapplicableforeachparticularnursingsetting.

Keywords(subjects)nurse,pediatrics,childdeath,copingmechanismMiscellaneous

1

Contents

1 Introduction....................................................................................................3

2 Childmortality................................................................................................4

2.1 Childmortalityrates...................................................................................4

2.2 Majorcausesofchildmortality..................................................................5

3 Pediatricnursing.............................................................................................6

3.1 Challengesinpediatricnursing...................................................................7

3.2 Nurses’experiencesfacingdeathofchildren.............................................9

3.3 Copingmechanisms..................................................................................11

4 Aim,purpose&researchquestion.................................................................12

5 Methodsandimplementationofthestudy....................................................13

5.1 Literaturereview......................................................................................13

5.2 Literaturesearch......................................................................................14

5.3 Dataanalysis.............................................................................................16

6 Results...........................................................................................................17

6.1 Socialsupport...........................................................................................18

6.2 Institutionalsupport.................................................................................20

6.3 Personalcopingstrategies........................................................................22

7 Discussion......................................................................................................26

7.1 Ethicalconsiderations,validityandreliability..........................................26

7.2 Discussionoftheresults...........................................................................28

References............................................................................................................33

Appendices...........................................................................................................40

Appendix1.Thereviewedarticlesinalphabeticalorder...................................40

2

Figures

Figure1.Majorcausesofunder-fivedeathsworldwide(2015)...................................6

Figure2.Inclusioncriteria...........................................................................................15

Figure3.Exampleofdataanalysisprocess.................................................................17

Figure4.Categoriesandsubcategories......................................................................18

Tables

Table1.Datasearch(duplicatesexcluded).................................................................16

3

1 Introduction

Modernmedicineaimstotreatandcure,however,careofthedyingandbereaved

alsoremainsasaroleofhealthcareprofessionals(Reynolds2006).Accordingtothe

WorldHealthOrganization’s(WHO)GlobalHealthObservatory(GHO)data(2017),

5.9millionchildrendiedin2015,mostofwhichhappenedintheWHOAfricaregion.

IntheEuropeanregion,11childrendiedoutofevery1000livebirthsin2015(WHO

2017).Basedonthesestatisticsitcanbededucedthatachilddyinginindustrialized

countriesisuncommon.Nevertheless,whenthisrarephenomenonoccursitisnor-

mallyatthehospitalafterthechildhasreceivedcomplex,andoftenlong-term,med-

icalcareaimedatcuringorcontrollingaseriousdisease(Docherty,Miles&Brandon

2007;Papadatou1997).

Achild’sdeath,ingeneral,isperceivedunfairandunexpected(Furingsten,Sjörgen&

Forsner2015).Comparedtootherhealthcareprofessionals,nursesspendmoretime

withthepatients,especiallyifapatient’shospitalstayisprolonged(Wilson&Kirsh-

baum2011).Hence,takingcareofpatientswhoaredying,andsimultaneouslysup-

portingtheirfamily,canbestressfulandtaskingfornurses.Furthermore,theanxiety

anduneasinessofdeathcanmakenurseslesscomfortablewhenprovidingsuchcare

(Peters,Cant,Payne,O’Connor,McDermott,Hood,Morphet&Shimoinaba2013).

Therefore,nursesinvolvedinthecareofdyingchildrenexperiencevariouschalleng-

esandobstacles.(Furingsten,Sjörgen&Forsner2015.)Duetodeathbeingaregular

occurrenceinanurse’slife,variouscopingmechanismsareessential,andtheability

tocopewhenencounteringdeathisavitalskilltohave.Moreover,inabilitytocope

withthedeathofachildhasbeenproventocauseharmtotheworkingabilitiesof

nurses.(Petersetal.2013.)

Thisresearchaimstoexplorethecopingmechanismsofnurseswhenfacingthe

deathofapediatricpatient.Thepurposeofthisresearchistoprovideinformation

4

onhowtoencounterthedeathofachildpatientandlearntoacknowledgetheidea

ofit.

2 Childmortality

2.1 Childmortalityrates

TheUnitedNation’sConventionontherightsofthechilddefinesachildasaperson

under18yearsold(YK1989).Basedontheirage,childrencanbedividedintodiffer-

entdevelopmentalgroupsasfollows.Logically,asthefirst28-day-periodofachild’s

lifeisreferredtoastheneonatalperiod,childrenagedlessthan28daysarereferred

toasneonates.Predominantly,duringthefirstyearoflife,childrenaredescribedas

infants.Thereafter,they’retoddlersupuntiltheageofthreeyears,andpreschoolers

attheageofthreetosixyears.Childrenfrom7to12yearsofagearedefinedschool

aged,andfinally,adolescentsfrom12to18yearsofage.(Storvik-Sydänmaa,Tal-

vensaari,Kaisvuo&Uotila2012,11.)

AccordingtoWHO(2016)globally,5.9millionchildrendiedbeforereachingtheage

of5in2015.Thenumberisequivalenttoabout16000fatalitieseveryday.Although

under-fivemortalityratesaredecreasingglobally,theratesremainremarkablyun-

balancedbetweenhigh-andlow-incomecountries.Thesub-SaharanAfricaisbattling

thehighestriskforunder-fivemortality,theriskbeingabout14timeshigherthanin

thedeveloped,high-incomeregions(WHO2016).Lookingatthebiggerpicture,in

high-incomecountries7outof10deathsareamong70-year-oldsandolder,with

only1outofevery100deathsamongchildrenunder15years.Incomparison,inlow-

incomecountriesnearly4inevery10deathsareamongchildrenunder15years,and

only2inevery10amongpeopleaged70andolder.(WHOn.d..)

5

Duetosocioeconomicdevelopmentandimplementationofvariousinterventionsfor

thesurvivalofthechildren(Black,Cousens,Johnson,Lawn,Rudan,Bassani,Jha,

Campbell,FischerWalker,Cibulskis,Eisele,Liu&Mathers2010),childmortalityrates

intheAfricanregionhavealsodecreasednotablywithinthelast10years(Ashorn

2016).Eventhoughthispositivechangehasbeenseeninthedevelopingcountries,

therearestillcountriesthathaven’tchanged.Thethreeprinciplefactorsessentialfor

children’shealthareshelter,foodandpotablewater.Nevertheless,thesebasicre-

quirementsarenotfulfilledaswellinthelow-incomecountriesasinthehigh-income

countries.Theabsenceofevenoneofthesefactorscanendangerthehealthofa

child.Withoutshelter,childrenareexposedtoallkindsofenvironmentalhazards

suchascold,radiation,infectionsand,withinwarzones,evenexplosives.Itisbe-

lievedthatabout200millionchildren,undertheageof5,livestarvingandwithout

enoughsourcesforcleanwater,thuspredisposedtovariousmedicalconditions.

(Ashorn2016.)

2.2 Majorcausesofchildmortality

Achild’sriskofdyingishighestduringthefirst28daysoflife,alsoknownasthene-

onatalperiod.Furthermore,45percentofdeathsundertheageof5yearsoccur

withintheneonatalperiod.Mostoftheneonataldeathsareduetoprematurity,

complicationsduringbirthorinfections.Theleadingcausesofdeathamongchildren

agedmorethan28daysbutlessthan5yearsarepneumonia,diarrheaandmalaria.

(WHO2016.)Additionally,nearlyhalfofallunder-fivedeathsareconsequenttoun-

dernutrition.Thus,mostchilddeathsaresubsequenttoconditionsthatareeither

preventableortreatable.Statisticsofthemajorcausesofunder-fivefatalitiesin2015

arepresentedinfigure1.(Levelsandtrendsinchildmortality2015,8.)

6

Theriskofdyingbeforereachingtheageoffiveremainshighestinthesub-Saharan

Africa(WHO2016).Nevertheless,intheEuropeanregionunder-fivemortalityisalso

duetopreventablecauseslikepneumoniaanddiarrhea.Inaddition,therearewarn-

ingsignsoftherecurrenceofdiseasessuchasdiphtheriaandtuberculosis.Non-

communicablediseases,suchasasthma,aswellasmorbidityfromsubstanceabuse

arealsoincreasing.(WHO/Europen.d.)LookingatspecificcountriessuchasFinland,

theleadingcausesofdeathamongchildrenunder1-year-oldsarecertainperinatal

conditions,congenitalmalformationsandchromosomalabnormalities.Among1-4-

year-oldsthemostcommoncausesareaccidents,tumorsandinfectiousdiseases,

whileattheageof5-14accidentsandtumors.(Tapanainen&Rajantie2016.)

Figure1.Majorcausesofunder-fivedeathsworldwide(2015)

3 Pediatricnursing

7

3.1 Challengesinpediatricnursing

Apediatricnurseisanursewhoisinvolvedinthehealthcareofachildfrominfancy

throughadolescence.Pediatricnurseshaveanoverallgoalofprovidingoptimal

healthcaretotheirclientswhiletakingintoaccounttherolefamiliesplayintheir

client'swellbeing(Kyle2008,Linnard-Palmer&Coats2016,283.)Pediatricnursesare

presentinallthethreemajorlevelsofhealthcare.Intheprimarylevel,theycanpro-

videcareinplaceslikehealthcarecenters,schoolsandevendaycarecenters.Inthe

secondarylevel,pediatricnursescanbefoundprovidingcareinpediatricintensive

units,surgicalunits,andemergencydepartments.Lastly,intertiarycenterstheycan

befoundinrehabilitationcenters,endoflifecareandhomecareagencies(Linnard-

Palmer&Coats2016,284.)Althoughdifferenttypesofnursesinalllevelsofcare

mighthavevariousrolesandresponsibilities,whencaringforachild,allofthem

mustensurethatcommunicationisbasedonthechild’sageanddevelopmentlevel

(Kyle2008).

Communication

Communicationisthemostcommonprocedureinnursing.Itisintimatebecauseof

theveryprivateissues,suchashopes,fears,mentaldisordersandterminalillnesses,

discussed.Itisthefoundationoftherapeuticrelationshipsbetweennursesandtheir

clients.(Levetown2008.)Despitecommunicationbeingacriticalcomponentofcare,

itoftenfaceschallengesespeciallyinpediatriccarewhichrequiresconsideringthe

client’sfamilyaspartoftheholisticcare(Blackstone&Pressman2011).Another

challengeiscommunicatingwiththechildpatientasconsiderationisrequiredon

cultural,ethical,relationalanddevelopmentallevels(Levetown2008).Perhapsthe

mostchallengingpartofcommunicationinpediatricnursingiswhen‘badnews’have

tobegiventoapatient.Discussingtheneedtotakemedicationfortherestofone’s

lifeforachroniccondition,anunanticipatedbloodtestforaneedlephobicchild,or

talkingabouthospiceandpalliativecareforachildmayfeeluncomfortabletoa

nurse,resultingtoemotionaldistress(Berlinger,Barfield&Fleischman2013).

8

Emotionallabor

Maunder(2008)aswellasBailey,MurphyandPorock(2011),refertoHochschild`s

(1983)definitionofemotionallaborastheabilitytodisplayone’swayofworkingina

waythatmakesothersfeelcaredfor,bymanagingone’sownfeelingsandemotions.

Nursesdothisbymakingtheirclientsfeelsafe,comfortableandbybeingavailable

forthem.However,itisofnodoubtthatnursesexperienceemotionalstresswhen

puttingupthisprofessionalwall,especiallyiftheytakecareofachildformanyyears

asinthecaseofpediatricpalliativecare.(Maunder2008.)Thisemotionalstressmay

beaccompaniedbyburnoutandattritionifanurseusesoneofthetwostrategies

usedtoperformemotionallabor,calledsurfaceacting.Surfaceactinginvolvesdis-

playoffakeorganizationallydesiredemotions,whereasdeepactinginvolvesmodifi-

cationofone’srealemotionstoalignwithemotionaldisplayrules.(Golfenshtein&

Drach-Zahavy2014.)

Grief

Itisnotuncommonforpediatricnursestoformaspecialbondwhencaringfortheir

patientsandtheirfamilies.Itisthisuniquecaringrolethatcanexposeapediatric

nursetofrequentandintenseexperienceswithunresolvedlossandgriefwhentheir

patientsdie(Adwan2014).Griefisunderstoodastheemotionalstateofintense

sadnessresultingfromareactiontoalossinitstotality(Hall2011).Duetothecorre-

lationbetweengriefandburnout,nursestendtoexperiencebothemotionaland

physicalchronicexhaustion,depersonalization,andreducedpersonalaccomplish-

ment.Ifthisgriefisnotwelladdressed,itmayleadtofeelingsofdepression,hesita-

tiontoengageoroverinvestmentwithnewpatients,preoccupationwithdeathand

evenresignationfromwork.Consideringthedemandsofprovidingpatientcare,

9

thereislesstimefornursestoworkthroughtheirowngrief,andthustheytendto

adaptinadequatecopingstrategies.(Shinbara2009,17-19.)

3.2 Nurses’experiencesfacingdeathofchildren

Fewstudiesexistontheexperiencesofnursescaringfordyingchildren.Oneinter-

estingarticlethatstandsoutisbyPapadatou,MartinsonandChung(2001)where

theycomparepediatrichospicenurses’experiencesintwodifferentcountries.An-

otherstudybyDocherty,MilesandBrandon(2007)focusesonnurses’experiences

whenthe`dyingpoint`,wherecurativecareendsandpalliativecarebegins,is

reached.

Duetochildrendyingbeingagainsttheorderofnature,nursesaremoreaffectedby

thedeathofchildren,evenifmassiveeffortsandheroicmeasureshavebeentaken

tosavetheirlives(Morgan2009).Withthedeathofachild,thefeelingsoffailureon

thepartofhealthcareprofessionalsareperceivedinthreeparts.Theprovidersof

carefeeltheyhavefailedthechildbecausetheycouldnotsavehislife,andfeelthey

havefailedintheirsocialroleasadultstoprotectthechildfromharm.Lastly,they

feeltheyhavebetrayedtheparentswhotrustedthemwiththemostvaluablebeing

intheirlife.(ibid.)

AccordingtoDunn,Otten&Stephens(2005),issuesthataffectnurses’attitudesto-

wardscaringfordyingpatientsdependsontheirpersonalexperiences(age,race,

religion,attitudestowardsdeath),pastexperiences(levelofeducation,deathtrain-

ing)andprofessionalexperiences(monthsofnursingexperience,percentageoftime

spentincontactwithterminallyillordyingpatients).Moreexperiencedandcompe-

tentnurseshavecopingstrategies,intuitiveawareness,andtheabilitytoprovide

10

holisticcaretotheirdyingpatientswhereasnursesbeginningtheircareersstillrely

onasetofgivenrulesandguidelinestoprovidecare(ibid).

Feelingsoffearandaversionarecommonamongnurses.Theyfeelhelplessanduna-

bletoprovidegoodqualitycare,whentheyareincapabletoalleviatechildren’semo-

tionalandphysicalpainandsufferingaswellastheparents’fearanddistress.They

grieveoverthesufferingexperiencedbyparentsandoverthelossoftheirpersonal

goalsandexpectationsinrelationtothechild’scare.(Papadatouetal.2001.)Along-

sidefearandgrief,nursescanalsofeelangerintertwinedwithguiltandblameofself

andothers,especiallyifthemannerinwhichachilddiesisconsideredtobesense-

lessorpreventable.Theyblamethemselvesfornotspeakingup,fornotdoingwhat

theycouldhavedone,formissingsomethingorfordoingsomethingwrong.(Clem-

ents&Bradley2005;McDevitt2003;Rashotte,Bourbonnais&Chamberlain1997.)

Afterthedeathofapediatricpatient,nursescommonlyfeelintensesorrowbecause

theytendtoformanemotionalattachmentwiththechildandthefamily(Durall

2011).Dissonance,whichisthecontradictionbetweennurses’beliefsorexpecta-

tionstotherealitysurroundingachild’sdeath,greatlyintensifiesthenurse’ssorrow

aswellasthedurationofgrief(Alligood2013,201;Rashotte,Bourbonnais&Cham-

berlain1997).

Deathrelatedactivitieslikecleaningthebodyandtransportingittothemorgueare

partofanurse’sjob.Nursesfinditimmenselydifficulttoleavethechildinacold

barrenenvironment,furthermoreorganization’sproceduresoncaringforthede-

ceased'sbodyrequiresnursestofacethefinalityofthechild'sdeathbeforetheyare

emotionallyreadytodoso.Becauseofthis,nursesareforcedbytherealityoftheir

situationtoperformtaskstheyarenotreadyfor.

“Buttheworst,theworstfeeling,[pause]IhadwaswhenIbroughthimtothe

morgue[shudders].Wewentintothemorguewheretheyputthebodies,andthere

11

wasnobodyinthere,anditwascold.Itwas,[pause]horrific.LikeI,Iput[child's

name]down,andIgavehimagreatbighug,andabigkiss[crying],andhewasgo-

ingtobealoneinthere,[pause]allnight[sniffles].Andtherewasnomorerespect,

therewasnomorelove,therewasnomorefeeling...Itwasruthless.Idon'tknowif

that'sagoodwordtouse,but[sigh].Itwasbad.”(Rashotte,Bourbonnais&Cham-

berlain1997.)

Nevertheless,somenursesfeelsignificantlyrewardedbytheirwork.Theygaindeep

satisfactionfromtheircontributioninthecare,astheyperceivetheworktobeboth

verydifficultandmeaningful.Manyofthenursesdescribetheirroletobe“uniqueor

special”.(Papadatouetal.2001.)

3.3 Copingmechanisms

Thetermcopingcomprehendsalltheeffortsthatapersondoestomanage,accept

orreducetheinternalandexternaldemandsandstressorsthatareperceivedtaxing,

stressingoreventhreatening(Beh&Loo2012).Furthermore,copingisthecapacity

torespondandrecoverfromburdensomeandstressfulevents.Copingmechanisms,

therefore,aretheremedialactionstakenbyapersonwhosesurvivalisendangered.

Copingstrategiesdifferbyaperson'sattitudes,region,community,gender,social

group,age,religion,familyanddifferentseasons.(WHO/EHA,1999.)Additionally,

thelevelofexperience,andtheunitanurseworksinalsoaffectthecopingmecha-

nisms(WahMak,Chiang&Chui2013).

Inhealthcaresettings,nursesaretheoneswhodevelopmorepersonalrelationships

withtheirpatientsduetofrequentandclosecontactwhenprovidingcare(Peterson,

Johnson,Halvorsen,Apmann,Chang,Kershek,Scherr,Ogi&Pincon2010;Wilson&

Kirshbaum2011).Facingdeathcanbeahighlystressful,intenseandchallengingsitu-

ationfornurses(WahMaketal.2013)leadingtovariousphysical,cognitive,behav-

12

ioral,spiritualandemotionalreactions.Copingmechanismsareessentialformanag-

ingwiththenursingprofession.(Wilson&Kirshbaum2011.)

Previousstudiesconcerningcopingmechanismsorstrategiesinnursingconcernonly

adultdeaths.Moreover,moststudiesfocusonfactorssuchasworkrelatedstress,

burnoutandPTSD(Hinderer,VonRuered,Friedmann,McQuillan,Gilmore,Kramer&

Murray2014;Chipas,Cordrey,Floyd,Grubbs,Miller&Tyre2012).Thestudysettings

aremostlyfocusedonhospiceorpalliativecare(ChiHoChan,Fong,LokYWong,

ManWahTse,ShingLau&NgorChan2016;Desbiens&Fillion2007)andcriticalen-

vironments(WahMak,Chiang&Chui,2013;Shariff,Olson,SantosSalas&Cranley

2017).Furthermore,evenwithinthefieldofpediatricnursing,commonlymetpoints

ofviewarethoseofapatient’sfamily,mostlyparents’.Thefamily’scopingwiththe

deathofachild,andthewaysnursesaresupportingthefamilyarealsofrequentsub-

jectsofresearch.(AbibElHalal,Piva,Lago,ElHalal,Cabral,Nilson&Garcia2013.)

Hence,researchconcerningnurses’copingmechanismswhendealingwithchild

deathislacking.

4 Aim,purpose&researchquestion

Theaimofthisstudyistoexplorethecopingmechanismsofnurseswhenfacingthe

deathofapediatricpatient.Thepurposeofthisstudyistoprovideinformationon

howtoencounterthedeathofachildpatientandlearntoacknowledgetheideaof

it.Thisinformationcouldbeusedtoeducatefuturenursesandnursesworkingin

variousfields.

Researchquestion:

• Whatkindsofcopingmechanismsareavailablefornurseswhenfacingthe

deathofapediatricpatient?

13

5 Methodsandimplementationofthestudy

5.1 Literaturereview

Areviewofliteratureisawrittendocumentpresentedinalogicallyarguedmanner

leadingtoacomprehensiveunderstandingofthecurrentstateofknowledgeabouta

particulartopicofstudy.Itinvolvesinterpretingaselectionofdocumentsfromvari-

oussources,bothpublishedandunpublished,withtheaimofansweringresearch

questions(Wiliams&Vogt2011,184)andprovidingasoundbaseonwhichnewre-

searchideascanbefounded.(Oliver2012,1.)

Thismethodwaschosenforthisreviewtodevelopinsightsonthecopingmecha-

nismsofpediatricnurseswhentheirclientsdie.Thedecisiontonotlimitthisstudyto

aparticularcountryallowsfortheresultsoftheresearchtobeusedinevidenced

basedpracticeuniversally.Thisalsoprovidesthereadersofthisstudyalargerbody

ofanalyzedresearchinonetext(Aveyard2007,4).

Anevidencebasedliteraturereviewshouldbedoneinasystematicexplicitmanner

withareproduciblemethodforidentifying,evaluatingandsynthesizingexistingwork

producedbypreviousresearches(Fink2010,3).Unlikethenarrativereviewthatis

likelytobeinfluencedbyaresearcher`sinterest(Saks&Allsop2007,34;Bettany-

Saltikov2012,9),asystematicreviewrequiresarigorousresearchmethodologywith

limitedbiasinallaspectsofthereview(Bettany-Saltikov2012,5-9).Asystematic

reviewcallsforastringentmeta-analysisofdataandrequiresresearcherstoinclude

detailsofbothusedandnotusedstudiesthatstayrelevantwiththeresearchques-

tions(Gaerish&Lathlean2015).

14

AsoutlinedbyMachiandMcEvoy(2012),theprocessofaliteraturereviewconsists

ofsixbasicsteps.First,selectionofatopic,followedbysearchingtheliterature,then

developinganargument,andsurveyingtheliterature.Critiquingtheliteraturecomes

nextandfinally,writingthereview.Asthefirststep,asubjectthatoriginatedfrom

theinterestsoftheresearcherswasformulatedintoatopicofresearch.Asthese-

condstep,theliteraturewassearchedbymanagingdata,scanningandskimming

literature,mappingmaterialandcreatingsubjectmemorandathatleadtorefining

theresearchtopic.

Thethirdstep,developinganargument,includedbuildingthecasefortheliterature

reviewbyunderstandingclaims,buildingevidenceandlogicallyconnectingevidence

andclaim.Thus,multipleclaimargumentswereformedtobeusedinwritingthe

review.Thefourthstepconsistedofimplicativereasoning,formulatingargument

patternsandbackingtheargumentsinordertoavoidfallacies.Finally,thelaststep,

writingthereview,involvedtwoprinciplesofwriting:tounderstandandtobeun-

derstood.(4-159.)

5.2 Literaturesearch

TheliteraturesearchwasconductedduringlateFebruaryandearlyMarch2017,af-

terdefiningtheresearchquestion,searchtermsandtheinclusionandexclusioncri-

teria.Theliteraturewasreviewedbythreeindividualresearcherstominimizebias.

Theprocessofselectingtherelevantstudiesforareviewconsistsoftwophases(Bet-

tany-Saltikov2012,84).Accordingly,thesearchresultswerefirstprocessedbasedon

titleandabstracttoexcludeirrelevantresults.Inthesecondphase,fulltextsofthe

resultspassingthefirstphasewerereadtofurtherdeterminewhethertheinclusion

criteriawasmet.Figure2demonstratestheinclusioncriteriaforthisliteraturere-

view.Theinclusioncriteriawasselectedinordertofindcurrent,relevantandhigh

15

qualityresearchmaterial.Theresultsnotfulfillingtheinclusioncriteriawereauto-

maticallyexcluded.

Inclusioncriteria:

• Freefulltextaccessforstudents

• Scientificpublication

• Peerreviewed

• Publishedbetween2010-2017

• StudyinEnglish

• Answerstheresearchquestion

Figure2.Inclusioncriteria

Thedatafortheliteraturereviewwasgatheredusingthefollowingtwodatabases:

CinahlandJYKDOK.ThesearchtermsusedwerepediatricsANDdeathANDnurse,

andcopingANDchilddeathANDnurses.Booleansearchwasused.Twooptionsof

searchwordswerechosenandappliedinordertogainmoreresultswithinthedif-

ferentdatabases.Bothoptionsofsearchtermswereusedtoconductasearchin

eachdatabase.Basedonthesearch,atotalof11articleswerechosentobere-

viewed.Duplicateswereexcludedfromthefinalnumberofarticles.Table1demon-

stratesthedatasearch.AtableofallthereviewedarticlescanbefoundinAppendix

1.

16

Table1.Datasearch(duplicatesexcluded)

Database Searchterms Results Chosen

basedonthe

titleand

abstract

Relevant

studies

Cinahl

pediatricsAND

deathAND

nurse

41

9

7

Cinahl

copingAND

childdeathAND

nurses

6

2

0

JYKDOK

pediatricsAND

deathAND

nurse

34

4

0

JYKDOK

copingAND

childdeathAND

nurses

122

6

4

5.3 Dataanalysis

Thepurposeofdataanalysisistobringtogetherthefindingsprovidedbythearticles

reviewedandthusproduceaninterpretationthatismoresubstantivethanthose

resultingfromindividualarticles(Aveyard2010,124).Contentanalysisiscommonly

usedinnursingstudieseitherintheformofinductiveordeductiveanalysis.Moreo-

ver,contentanalysisisanoptionforqualitativeapproacheswhenprovidingevidence

concerningsensitivetopics.Inductivecontentanalysiscanbeusedwhennoprevious

studiesaboutthephenomenoninhandexist,orwhenit’sfragmented.(Elo&Kyngäs

2008,107,114.)Therefore,aninductivecontentanalysismethodwaschosenand

followedtoconductthedataanalysisforthisresearch.

17

Aninductivecontentanalysiswasconductedfollowingthethreemainphases:reduc-

tion,clusteringandabstraction.(Tuomi&Sarajärvi2009,108).Itwasfurtherdivided

intothreesystematicphases:opencoding,creatingcategoriesandabstraction.Open

codinginvolvedhighlightingthemainfindingswithinthearticlesreviewed,andcod-

ingthemaccordingtothecontent.(Elo&Kyngäs2008,109-111;Tuomi&Sarajärvi

2009,109.)Thecodeswerewordsthatsummarizedthemainpointsofeachparticu-

larfinding(Aveyard2010,129-130).Inthesecondphase,similarcodeswereclus-

teredtogethertoformsub-categoriesandfurthermoremaincategories.Finally,in

theabstractionphasethecategorieswerefurthersynthesizedandnamedusingcon-

tent-characteristicwords(Elo&Kyngäs2008,111),thereforeformingtheoretical

conceptsandconclusions(Tuomi&Sarajärvi2009,111).Thedataanalysisprocessis

demonstratedinfigure3.

Figure3.Exampleofdataanalysisprocess

6 Results

18

Theresultsarefurtherpresentedwithinthreemaincategories:socialsupport,insti-

tutionalsupportandpersonalcopingstrategies.Figure4illustratesthemaincatego-

riesandtheirsubcategories.Theresultsarefurtherexplainedinthetext.

Figure4.Categoriesandsubcategories

6.1 Socialsupport

Peersupport

Theopportunitytoshareexperiences,feelingsandhardshipswithcolleaguesiscon-

sideredcrucialfornursesfacingthedeathofpediatricpatients(Cook,Mott,Law-

rence,Jablonski,Grady,Norton,Liner,Cioffi,Hickey,Reidy&Connor2012,18;Kel-

logg,Parker&McCune2014,298).Moreover,thisformofsocialsupport,referredto

aspeersupport,isoneofthemostcommoncopingstrategiesappliedbynursesin-

volvedinthecareofdyingchildren(Forster&Hafiz2015,295;Maloney2012,112;

Reid2013,33).Discussingexperienceswithcolleaguesishelpfulwhenfacingsudden

•Peersupport•Supportprovidedbyfamilyandfriends

Socialsupport

•Debriefingsessions•Otherformsofinstitutionalsupport

Institutionalsupport

•Emotionalprocess•Compartmentalization•Focusingonthepositive•Spiritualbeliefs

Personalcoping

strategies

19

overwhelmingemotions,andduringtheprocessofgrievingthelosses(Cholette&

Gephart2012,17;Kelloggetal.2014,298;Pardoe2011,27).

Peersupportallowspediatricnursesto,informally,sharetheirexperiences,andfur-

thermoreexpresstheirfeelingsrelatedtoparticularcasesinvolvingchilddeath(Kel-

loggetal.2014,298;Maloney2012,112;Reid2013,33).Colleaguesareseenasa

valuablesourceofsupportduetotheiruniqueabilitytorelatetotheexperiences.

Furthermore,peersareperceivedtohavegonethroughthesamethings,tobefamil-

iarwiththeenvironmentandto‘beinitwithyou’.(Cooketal.2012,18;Forster&

Hafiz2015,295;Kelloggetal.2014,300;Stayer&Lockhart2016,354.)Thestudyby

Reid(2013,33)suggeststhatcolleaguesarehelpfulin“figuringthingsout”,whereas

StayerandLockhart(2016,354)identifysituationswhere“colleaguestrytocheer

youup”.Additionally,Kelloggetal.(2014,300)introduceaphysicalformofcollegial

support:“somepeoplewillfallapart--theyareasobbingmess,andsomebodygoes

intheretohugthemandtalktothem”.

Asaresultofthesenseofsharedexperience,thecomfortgainedfrompeersupport

isseentohavethemeanstoprovidetheaffected,grievingnurseswithpositivevali-

dation,closure,senseofpurpose,enhancedself-confidenceandthustheabilityto

continueworkingintheirunits(Forster&Hafiz2015,296;Stayer&Lockhart2016,

354).Finally,thisformofsocialsupportcanlessenwork-relatedstress(Maloney

2012,112)andasdescribedbyÅngström-Brännström,Dahlqvist,Strandbergand

Norberg(2014,7),thepositiveeffectcanalsobeseenhelpfulinbeingpresentfor

thedyingchildandthefamily.Inspiteofthevariouspositiveeffectsfound,Forster

andHafiz(2015,295-296)explainthatapossiblenegativeimpactofpeersupportis

thatthedistressratherexacerbatesasaresult.

Supportprovidedbyfamilyandfriends

20

Fewofthestudiesrevieweddescribethatsomenursesfindcomfortintheirfamilies

whencaringforadyingchild(Forster&Hafiz2015,297;Kellogg,Barker&McCune

2014,300;Pardoe2011,28;Stayer&Lockhart2016,354).Althoughnotencountered

inthereviewasoftenaspeersupport,somenursesalsoseeksocialsupport,and

furthermorecomfort,byconfidingintheirpartners.Thisformofsocialsupportis

describedforexampleasdebriefingwithsupportivepartners,talkingtospouses

aboutbadcasesandhavingone’sfamilymemberstheretolistenandtalkwith.(For-

ster&Hafiz2015,297,300;Kelloggetal.2014,300;Stayer&Lockhart2016,354.)A

spouse’sexperiencefromsimilarsettingsandthusabilitytorelatecanalsobefound

useful(Kelloggetal.2014,300).

Furthermore,thestudybyKelloggetal.(2014,300)alsospecifieschildrenasa

sourceofcomfortasfollows:“thefirstthingIwanttodo[afteracaseofpatient

death]isclimbintobedandhugmyownchild”.Finally,oneofthearticlesreviewed

alsogivesinsightintoharnessingsupportbytalkingwithone’sfriends(Pardoe2011,

28).Althoughfamilycanbeconsideredasatoolforcoping,nurses’professionalcon-

fidentialityremainsanissuewiththistypeofsocialsupport(ForsterandHafiz2015,

297).

6.2 Institutionalsupport

Debriefingsessions

Oneinstitutionalresource,createdbyapediatricpalliativecareprogram(Harriet

LaneCompassionateCare)inJohnsHopkinsChildren’sCenter,isthebereavement

debriefingsession,whichaimstoprovideemotionalsupport,increasetheabilityto

manageone’sgriefandfindmeaningwhencaringforchildrenwithlife-threatening

conditions.Thesevoluntarydebriefingsessionsareofferedforallhealthcareprovid-

ersaftereachpatientdeath,andcanbeheldwithinaweekaftertheincidentina

privatesetting.Thepurposeofthesesessionsistocompareandsharedifferent

21

healthcareproviders’emotions,experiencesandresponsestodeathand,further-

more,copingmethods.Ultimately,thesedebriefingsessionsleadtoprovidingsup-

portandsharingwisdomfrommoreexperiencedcolleaguestothenewerones.

(Keene,Hutton,Hall&Rushton2010,185-186.)

Anotherquitesimilar,structuredprocessisCriticalIncidentStressDebriefing(CISD),

whichwasspecificallydesignedforthehealthcareprofessionalsencounteringtrau-

matizingeventsandemergencies(Maloney2012,111).CISDcanbeappliedafter

variouskindsofevents,notonlythosedealingwithapatientdeath(Keeneetal.

2010,185).Therefore,thisdebriefingmethodsupportsdealingwiththephysicaland

psychologicalsymptomsevokedbyatraumaticincident(Maloney2012,111).The

timingforCISDshouldbewithinhoursaftertheincident,andlocatedneartothesite

ofthetraumaincident.Thus,comparedtoBereavementDebriefingsessions,the

CISDsessionsaremoreacute.CISDisconsideredareviewoftheincidentsbefore,

duringandafterthecrisis.Itallowsthehealthcareprofessionalstoprocessandre-

flecttheincident,andfurthermoreallowstoventilatethoughtsandemotionsassoci-

atedwiththetraumatizingevent,thussupportingthehealingprocessofthestaff.

(ibid,110-111.)

Otherformsofinstitutionalsupport

Someinstitutionsoffermentoringprograms,whereanewlygraduatednurseis

matchedwithanexperiencednurseforsupportandlearningcopingmechanisms

(Maloney2012,111).Additionally,othermentoringprograms,peerorteamsupport

meetingsandclinicalsupervisionarementioned(Maloney2012,112-113;Pardoe

2011,28).AstudybyCook,Mott,Lawrence,Jablonski,Grady,Norton,Liner,Cioffi,

Hickey,ReidyandConnor(2012)introducesthePediatricAdvancedCareTeam

(PACT)asamajorformofsupportinthepediatricsetting,whendealingwithdying

childrenandtheirfamilies.Theteamassistsboththefamiliesandtheprofessionals.

PACTiscomposedofanursepractitioner,physicians,asocialworkerandacoordina-

22

tor,whohaveallreceivedadditionaltrainingforpalliativeandend-of-lifecare.PACT

facilitatesdiscussionsaboutdeath,andassiststhehealthcareteamwithdecision-

makingandexploringtreatmentoptionsandgoals.Moreover,PACTprovidesaguide

toqualityandmeaningfulend-of-lifecareandassessingproperpainandsymptom

managementforthechild.Asaresult,manynursesexpressfeelingsofreliefanddi-

minishmentofpressureincare,becauseofthepresenceandsupportofthePACT.

(18.)

Finally,anissuethatispointedoutaslackinginmanysystemsiseducation.Never-

theless,someofthearticlesalsodiscusseducationprovidedforhealthcareprofes-

sionals.Palliativecareeducation(Keenan&MacDermott2016,22;Keene,Hutton,

Hall&Rushton2010,186),forumsandconferencesforclinicalsupportandritualsfor

remembrance(Keeneetal.2010,186),arementionedaseducationalresources.Psy-

chologicalsupportaswellassessionswiththehospital’spsychologistarealso

sourcesforsupportingnursescoping(Pardoe2011,28).

Someinstitutionsalsoprovidedifferentkindsofrelaxationmethods,suchastran-

quilityrooms,therapies(aromatherapy)andmassagechairs.Somearrangements

requestedbynursesthemselves,suchasreflexologyandothertypeoftherapiesare

alsomentionedinthereviewedarticles.(Forster&Hafiz2015,297;Maloney2012,

112).Nevertheless,workingintensivelywithfamiliesandtheirdyingchildrenhasa

highinfluenceonsomeoftheprofessionals,leadingtotheneedofsickleave.This

personalcopingstrategyprovidedbytheinstitutionisvitalforsomehealthcarepro-

fessionals.(Forster&Hafiz2015,297.)

6.3 Personalcopingstrategies

Emotionalprocess

23

Theneedtotakecareofoneselfisexpressedbymanynurses.Somenursesdothisby

exercisingafterexperiencingalossoftheirpatients,somebyrelaxing,eatingwell

andbasicallypamperingthemselves.(Kelloggetal.2014,300;Pardoe2011,29.)

Knowingthattheyhavedonealltheycouldfortheirpatientsandhavinghadestab-

lishedatrustfulrelationshipwiththechildandtheirfamilyalsohelpsnursestoper-

sonallycopewiththedeathoftheirclients.Inthecasethatthistrustisestablished

throughoutthecourseoftreatmentthenursefeelscomfortedbecausesheknows

thathercarehasmadeadifferenceandshehashelpedalleviatethechild'spain.

(Ångström-Brännströmetal.2014,6.)

Acknowledgementoflosswhileexpressinggriefandsorrowisusedbynursestocope

withthedeathoftheirchildpatients.Acceptingthatdeathispartofanurse`slife

allowsnursestofacetherealityandmoveontocaringfornewpatients.(Cholette&

Gephart2012,298.)Somenursesexpresstheirsorrowopenlybycryingwhenthey

loseachildpatient,andsomeevencrywiththebereavedfamilies(Kelloggetal.

2014,299).ItisnotedbyKelloggetal.(2014)thatalthoughnursesarepreparedto

dealwithfamiliesduringillnessesandloss,theirreleaseofemotionswhentheylose

achildpatientisminimalandthismayleadtofrustrationandcareerfatigue.Forthis

reason,nursesshouldhavetheabilitytomanagetheirgrieftoavoidnegativeimpli-

cationsontheirprofessionalpractice(298).

Compartmentalization

Compartmentalizationisdonetomaintainanoutwardprofessionaldemeanorandto

continuecaringforthebereavedfamilies.Itinvolvessettingone'sfeelingsasidein

ordertogoonwiththejob,butthenworkingonthosefeelingslater.Nursesfeelthat

thiscopingskillaffordsthemtimetoworkthroughtheiremotionsandconflicting

feelingsofthedeathofachildatalatertime(Forster&Hafiz2015,296-297,300;

Kelloggetal.2014,299-300.)Compartmentalizationisdifferentfromdisconnecting

whichinvolvesturningoffone'semotionalsideanddoingone'sjobofcaringand

24

supportingtheliving,thebereavedfamilies,andnotworkingonthoseemotions

(Cholette&Gephart2012,17-18;Cooketal.2012,17).Tosomenurses,thiscoping

skillisextendedhomeastheyavoidtakingworkhomewiththemandthusemploy

strategiessuchaslabellingtoprotecttheirfamilies.Therefore,theyanswertoques-

tionssuchas‘howwaswork’by,forexample,sayingtheyhadabaddayinsteadof

sayingtheylosttheirpatients(Cooketal.2012,18.)

Finally,settingprofessionalboundaries,byplacingtheprofessionalandpersonalline

betweenfamilymembersandstaff,isalsoawaysomeofthenursescope.Nurses

usethislineasaguideonhowinvolvedtheyshouldbe.Furthermore,theyusethisto

maintainanemotionalseparationthusavoidingburnout.Nevertheless,thesenurses

acknowledgethattheprofessionallineissomewhatfluid,asthelevelofinvolvement

changesfromonepatienttoanother.Thetermprofessionalboundariesisdescribed

asuncomfortableforsomenurses,astothemthetermimplies‘notcaring’.There-

fore,thisissimplynotanoptiontoallnurses.(Cooketal.2012,15-18.)

Focusingonthepositive

Whenpersonallydealingwiththedeathofapediatricpatient,nursesfindfocusing

onthepositivetobeausefulcopingmechanism(Keenan&MacDermott2016,21-

22).Somenursesdescribetheneedtomakesomegoodoutofabadsituation,even

beforeachildpasseson.Theydothisbyprovidingasmuchcomforttothechildand

thechild'sfamilyastheycan.(Stayer&Lockhart2016,353.)Furthermore,nurses

describetheneedtocreateapeacefulendingforthechildandthefamily,asthis

helpsthemfindandmakemeaningofthedeathofapediatricpatient(ibid.,354-

355).

Tosomenurses,focusingonthepositivemeansthattheytakeituponthemselvesto

studyaboutpalliativecare,ortodeveloptheirpracticeoncaringforthedying(Kee-

nan&MacDermott2016,19).Thesenursesacknowledgethatalthoughthese

25

measuresdonotchangetheirpreviousexperiences,itenablesthemtoknowthat

theyhavetheabilitytopreventsimilarsituationsfromhappeningand,hence,both

reducestheirpotentialguiltandbuildstheirconfidence(ibid.,21).

Focusingonmemoriesbyusingbedsidephotosofachildpatientisdescribedhelpful

bysomenurseswhencopingwiththedeathoftheirpatients.However,somenurses

findtheuseofbedsidephotosmoredistressingthanhelpfulasseeingthecomplete

transformationtheirpatienthasmadefromahappychildtoadyingchildmakes

themsad.(Cooketal.2012,17.)Finally,thepromiseoftomorrowbringingwithita

cleanslate,anewchildtocarefor,anopportunitytogetbackonandtokeeptrying

isdescribedbysomenursesasanewbeginning,awaytofocusonthepositive

(Cholette&Gephart2012,16-17).

Spiritualbeliefs

Spiritualitycanbeseenasaformofpersonalcopingstrategy.Spiritualbeliefs,reli-

gionandattendingthechild’sfuneralforclosurearerecognizedascopingmecha-

nismwhenfacingthedeathandlossofachildpatient.(Forster&Hafiz2015,298;

Keenan&MacDermott2016,21-22;Reid2013,33,35-36.)Forsomenurses,spiritu-

alityishelpfulwhencopingwithpatientdeath,asmeaningmakingandexistential

questionsaboutlife’spurposearereviewed(Forster&Hafiz2015,297-298).Like-

wise,meditationisusedasacopingmechanismbysomenursestoprocessthe

death,andfindmeaningandcomfort(Kellogg,Barker&McCune2014,300).

Religionandfaith,beingapartofsomenurses’everydaylife,arealsoseenasacom-

fortingcopingstrategy(Keenan&MacDermott2016,22).Religiousbeliefsandre-

sources,Godandprayer,areusedascopingmethodswhensupportandmeaning

makingafterachild’sdeathisneeded(Forster&Hafiz2015,298;Keenan&Mac

Dermott2016,21-22).Finally,forsomenurses,funeralscontributetotheemotional

coping(Reid,2013,35).Therearecaseswherethenursesarenotpresentwhena

26

childpatientdies,andthustheyfeeltheyarenottheretosupportthechildandthe

family.Thiscanleadtonotgettingthesenseofpersonalclosure.Inthesesituations,

thesupportfromtheinstitutionfornursestoattendthepatient’sfuneralisveryval-

uable.(Keenan&MacDermott2016,21.)Moreover,funeralsareseenasritualsand

settingswherenursescouldgrieveopenly,acknowledgethedeathofthechildand

getthesenseofclosure.(Keenan&MacDermott2016,21;Reid2013,33,35.)

7 Discussion

7.1 Ethicalconsiderations,validityandreliability

Ethicsinresearchisdescribedasthenormsforconductsthatguidesmethods,pro-

ceduresorperspectiveswhenanalyzingandpresentingcomplexproblemsandissues

(Resnik2011).Mainprinciplesofethicsincluderespectforhumandignity,privacy

andautonomy.Theseprinciplesalsoincludehonestyinreportingdata,resultsand

proceduresandavoidingmisrepresentation,fabricationorfalsificationofdata.One

hastobecarefuloftheirownworkandkeepgoodrecordsofresearchactivities

(ibid).

Asthisstudywasbasedonthemethodologyofliteraturereviewwhereprevious

studieswereusedasrawmaterials,onemajorethicalissuearosearoundinterview-

ingchildren(Ångström-Brännströmetal.2014).Theauthorsofthisresearchdebated

theethicsofinterviewingadyingchildandthemother.Theyalsowonderedifitwas

sufficienttoconsiderthechild'sconsenttotheoriginalresearchers(Ångström-

Brännströmetal.2014)asapermissionforthemtousethedata.However,because

thisstudywasdonefromanurse`sperspective,thisdidnotpresentachallenge.

27

Byensuringappropriatereferencingandavoidingmisrepresentationofotherau-

thor`sworksastheirown,thewritersofthisresearchpracticedtheprincipleofhon-

estythroughavoidingplagiarismandfabrication(Price2014,46).Presentationof

dataandresultsthatarosefromthisresearchwasdoneinanhonestandcareful

manner,andrecordsoftheresearchprocesswaskeptintheformofphotographs.

Thiswasdonetoavoidanyclaimsoffalsification.

Thedegreetowhicharesearchislikelytobefreeofbias,believableandtrueiswhat

definesvalidity(Buckingham,Fisher&Saunders2008).Inordertoadheretothis

principleandavoidbias,theauthorsscrupulouslyresearchedliteratureandaccurate-

lydocumentedresearchdataandresults.Thiswasdonetoallowforreviewal,evalu-

ationandreproducibilityoftheresearch.Althoughunintentional,publicationbiasis

evidentinthisresearch,astheauthorsbeingstudentshadlimitedaccesstoexisting

literature.

Theliteraturereviewedinthisstudyisfromsixcountries:TheUnitedStates,Austral-

ia,NewZealand,Scotland,Ireland,andtheUK.ThelanguageusedisEnglishandthe

researchmethodswereallqualitative.Thislimitsthegeneralizationoftheresults

takingintoaccountthesimilaritiesinculturethatthe6countriesshare.Themeth-

odologybeingthesameinallthereviewedliterature,presentsalimitationinthe

variationswithinthestudiesthemselves.

Thearticlesreviewedinthisstudyhadbeenresearchedondifferentsettings:pediat-

ricintensivecareunits,pediatricpalliativecareunits,oncologycaresettings,perina-

talcareunits,pediatricburncareunits,emergency,traumaunits,andgeneralacute

careunits.ThestudybyKeenanandMacDermott(2016)wasopentonurseswork-

inginanyfieldwhohadcaredforachildwhohaddiedinthepastsevenyears.This

varietyofsettingsallowfortheresultsofthisresearchtobeappliedindifferent

fieldsofnursingandincreasesitscredibility.

28

Thisresearchwasdonewiththethemeofstabilityinmind.Carewastakentoensure

thatthestepsoftheresearchwereclearenoughtoallowforduplicationofthere-

sultsbyanotherresearcherifalltheotherfactorsremainedconstant.Literaturein-

clusioncriteriawasplainlyoutlined,ideasandthoughtspreciselycredited,andre-

viewedliteratureswereputunderthesameethicalguidelinesaprimaryresearch

studywouldhavebeenputthrough.Thiswasdonetoemploytheprincipleofrelia-

bilityinresearch.(Houser2008;Roberts,Priest&Traynor2006,41.)

Thenumberofauthorsofthisresearchbeingthreealsoincreasesthereliabilityof

thestudyasopennessintermsofdatasharing,discussionsandcriticisms(Resnik

2011)wasemployed.Thisallowedforreviewevenduringtheresearchperiod.How-

ever,allthreeauthorsbeingbeginnersinconductingaresearchmayaffectthequali-

tyofthestudyintermsofdatapresentationandreliability.

7.2 Discussionoftheresults

Nursesworkinginpediatricpalliativeorcriticalcarewherechildrendieeveryday,

someunexpectedlyandsomeafteralongend-of-lifecare,oftenhaveoverwhelming

experiences.Encounteringthesesituationsdailyhasanemotional,physical,spiritual,

behavioralandcognitiveimpactonnurses(Cui,Shen,Ma&Zhao2011,403;Keene,

Hutton,Hall&Rushton2010,185).Iftheseexperiencesarenotdealtwith,thenurs-

es’professionalpracticeandoutcomesofcarecanbeaffectednegatively(Cui,Shen,

Ma&Zhao2011,403;Keeneetal.2010,185;Maloney2012,111).Therefore,death

asaneventshouldbeconfrontedratherthanavoided(Cui,Shen,Ma&Zhao2011).

Nevertheless,asoftheseresults,itwasagreedbytheauthorsofthisstudythatallof

thecopingmechanismsintroducedmaynotbeapplicabletoeverypracticingnurse.

Simplythefactthateverynurseisdifferentfromage,genderornationalityalone

makesdiversityinthecopingbehaviors.Additionally,thestudybyCook,Mott,Law-

29

rence,Jablonski,Grady,Norton,Liner,Cioffi,Hickey,ReidyandConnor(2012),ana-

lyzedsomespecificfactorsthatinfluencethecopingbehaviorsofnurses.Afewmain

componentspointedoutwerethelevelofexperienceofnurses’,theyearsofprac-

ticeinaparticularunit,andthelengthoftimetheyhadcaredforaparticularpatient.

(18.)Basedontheresults,itseemsthathavingmoreexperiencemightcorrelateto

havingmoretoolsforcoping.Thenagain,eventhoughonecanlearntoacceptdeath,

itseemsunlikelytogetfullyaccustomedtoit.Religionandone’sownspiritualitywas

seentobothsupportanddisturbcoping.Anotherfactoraffectingnurses’copingwas

iftheyhadchildrenoftheirown(ibid.).Yet,beingawareofone’sownneeds,

strengthsandlimitationsisthekeytofindingthemostsuitablecopingmechanisms

(Furingsten,Sjörgen&Forsner2015,180).

Socialsupportwasintroducedasausefulcopingmechanismin9outofthe11arti-

clesreviewed.Basedontheresultsgainedwithinthisstudy,socialsupportcouldbe

perceivedasthemostcommonlyusedformofcoping,duetoitsextensiveavailabil-

ity.Furthermore,evenforundergraduates,peersupportseemstobethemostnatu-

ral,althoughsometimessubconscious,copingstrategy.However,surprisingly,oneof

thearticlesalsogaveinsighttoapossiblenegativeimpactofit.Forster&Hafiz(2015,

295-296)explainedthatpeersupport,asindiscussingwithcolleagues,mightactually

exacerbatethefeelingsofanxietyanddistress.Indemandingworkenvironments,

socialsupportmight,insomecases,contributetodistressratherthanrelief.Moreo-

ver,inadequateorpoorsupportmayevencauseadditionalstress.(Button2008,

509-510.)

Anotherissueraisedwithinsocialsupportwasmaintainingprofessionalconfidentiali-

tywhileapplyingfamilysupport(Forster&Hafiz2015,297).Confidentialityinhealth

careisexplainedastheactofkeepingpatientinformationprivateorsecret.Thus,

onlynecessarypatientinformationcanbesharedwithotherhealthcareprofessionals

whoneedtheinformationinordertoprovidecare.Inrelationtotheconceptofchild

death,itshouldalsobenotedthatapatient’srighttoconfidentialityremainsafter

30

death.(NMC2015.)Discussingpatientcasesathomemightbreachtoofarfromthe-

seregulations,andthereforeoneshouldbecarefulwhensharingtheseexperiences.

Withinthecategoryofinstitutionalsupport,twoUSA-basedarticlesexplainedthe

useofdebriefingsessions,criticalincidentstressdebriefing(Maloney2012)andbe-

reavementdebriefing(Keene,Hutton,Hall&Rushton2010).Thesetwoformsofde-

briefing,whenaccessibletodistressednurses,areausefultoolforcopingwiththe

casesofchilddeath.However,incomparisontosocialsupport,theavailabilityand

applicationofthesesessionsremainedaquestiontotheauthorsofthisstudy.

Thelackofeducationandthuspreparednessconsideringthedeathofapediatric

patientwasbroughtupbymanyofthearticlesreviewed(Forster&Hafiz2015;Kee-

nan&MacDermott2016;Kellogg,Barker&McCune2014;Reid2013).Overall,nurs-

eslackformaleducationinbothundergraduatecurriculumsandduringworkinglife.

Sufficienteducationthatconsidersdeathfromvarious,holistic,pointsofviewcould

helpnursestoconfrontdeathasaphenomenonmorenaturallyandtoprovidegood

qualitycare.(Ciu,Shen,Ma&Zhao2011,403-404;Edo-Gual,Tomas-Sabado,Bar-

dallo-Porras&Monforte-Royo2014.)AccordingtothearticlebyKelloggetal.(2014,

300),thephysicalaspectofcaringforthedeadmighthavebeendiscussed,butcop-

ingwiththepsychologicalaspectwasnotprocessed.Furthermore,insomecases,

thedeathofadultpatientswasaddressed,butinpediatricstheprocessofdyingwas

overlooked(Kelloggetal.2014,300).Thus,theresearchhighlightedtheneedfor

moreeducationinthisparticular,sensitiveareaofnursing.

Intermsofpersonalcopingstrategies,anissuediscussedbytheauthorswasthatin

somecasessettingstrictprofessionalboundariesmightcomeacrossasnotcaring.

Furthermore,assaidinthearticlebyCook,Mott,Lawrence,Jablonski,Grady,Nor-

ton,Liner,Cioffi,Hickey,Reidy&Connor(2012,15)“thedaywestopfeelingisthe

daythatweneedtoquit...ifwedon’tgetaffectedbyachild’sdeath,that’swhenyou

needtorethinkyourprofession”.It’svitaltodrawthelinebetweenoneselfasaper-

31

sonandasaprofessional.Therefore,it’salsoessentialtoknowthedifferencebe-

tweentherealfeelingof“notcaring”andthedismissalofone’sfeelingsduetopro-

fessionalboundaries.Secondly,asintensepersonalfeelingssuchasgriefandanxiety

areconsideredanaturalresponsetodeath(Cui,Shen,Ma&Zhao2011,403)it

seemsvitalfornursestorecognizeandacceptsuchfeelings,eventhoughitmight

sometimesbeperceivedunprofessional.

Anotherdilemmaariseswhenthefamiliesofthedyingchildexpectthenursetoem-

pathizeandgrievewiththem,whilethenursetriestomaintainprofessionalism

(Cholette&Gephart2012,14).Hence,tosupporttheparents,nursesmustbalance

theirownemotionalexpressionsaccordingtoeachuniquesituationandthefamily’s

wishes(Furingsten,Sjörgen&Forsner2015,179-180).Thequalityoftherelationship

formedwiththedyingchildandthefamilymightalsoinfluencethecopingofboth

partiesinvolved.

Finally,pediatricnursingalwaysrevolvesaroundthewholefamily,andthusthephe-

nomenonofachildpassingencompassestheemotionalprocessofboththefamily

andthenurse.Althoughthedeathofachildisdevastating,itcouldalsobeseenasa

reliefforasufferingchild.Interestingly,theremaybeconsiderabledifferencesto

howachild’sdeathiscopedwithwhenit’sduetoalong-termillnessandwhenit’s

sudden.Therefore,copingwithsuchoverwhelmingexperiencesisnotonlyvitalfor

thefamilybutalsoforthenursesinvolved.Thefamily’scopinghasbeenstudiedbe-

fore,whereaslessfocushasbeengiventothenurses’pointofview.Basedonthis

research,variouscopingmechanismsareavailablefornursesfacingthedeathofpe-

diatricpatients,butnotallofthemaresuitableforeachindividual.Theseresults

couldbeappliedtovariousnursingsettingsandforeducationalpurposesforunder-

graduates.

Theauthorsagreedthattheavailabilityandqualityofinstitution-basedcoping

mechanismsshouldberesearchedfurther.Additionally,toallowforefficientcoping

32

indifferentnursingsettings,furtherresearchisneededtodeterminewhatkindsof

copingmechanismswouldbebestapplicableforeachparticularsetting.Asanexam-

ple,inthecurrentworldnursesmightalsoworkinareasofconflictanddisaster

wheredeathofchildrencanbearegularoccurrence.Therefore,furtherresearch

shouldbeconductedonwhatkindsofcopingstrategiesareapplicableforsuchde-

mandingsettings.

33

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Appendices

Appendix1.Thereviewedarticlesinalphabeticalorder

Author(s) Publishing

yearand

country

Title Researchmethod Mainfindings

Cholette,M.,Gephart,S.M.

2012USA

AModelfortheDynamicsofBereavementCaregiving

Qualitativere-search:casestudy

Importanceofacknowledgementoflosses,strongsupportiveteams,asafevenuetoexpressandsharefeelings,andset-tingtimeasideforself-careandin-trapersonalre-flection.

Cook,K.A.,Mott,S.,Lawrence,P.,Jablonski,J.,Grady,M.R.,Norton,D.,Liner,K.B.,Cioffi,J.,Hickey,P.,Reidy,S.&Connor,J.A.

2012USA

CopingWhileCaringfortheDyingChild:Nurses’Experi-encesinanAcuteCareSetting

Qualitativere-search:focusgroups

Nurses’specificneedswhilecar-ingfordyingpa-tientsandim-portanceofsup-portivecolleaguesandotheravaila-bleresources.

Forster,E.&Hafiz,A.

2015Australia

Paediatricdeathanddy-ing:exploringcopingstrate-giesofhealthprofessionalsandperceptionsofsupportpro-vision

Qualitativere-search:socialcon-structionism

Nursescopebyusingpeersup-port,personalcopingstrategies,familysupport,andspiritualbe-liefs.

Keenan,P.&Dermott,K.M.ORisitPaterson,J.G.

2016Ireland

HowNursesGrieveForChil-drenWhoDieInTheirCare

Qualitativere-search:descriptivestudy

Nursesvaryinthewaytheyexperi-enceandmanagetheirgrief.

41

Keene,E.A.,Hutton,N.,Hall,B.&Rushton,C.

2010USA

BereavementDebriefingSes-sions:AnInter-ventiontoSup-portHealthCareProfes-sionalsinMan-agingTheirGriefAftertheDeathofaPa-tient

Qualitativere-search:ethno-graphic

Opportunitiesforexpressionofgriefandreflectionallowsnursestocontinuetopro-videcareeffec-tively.

Kellogg,M.B.,Barker,M.&McCune,N.

2014USA

TheLivedExpe-rienceofPedi-atricBurnNursesFollow-ingPatientDeath

Qualitativere-search:phenome-nologicaldesign

Nursesdevelopindividualcopingmechanismsandseekpeersupportwhendealingwithalossofapatient.

Maloney,C. 2012USA

CriticalIncidentStressDebrief-ingandPediat-ricNurses:AnApproachtoSupporttheWorkEnviron-mentandMiti-gateNegativeConsequences

Qualitativere-search:casestudy

Debriefingisamodelofcopingtosupportstaffhealingfollowingacriticalincident.

Pardoe,P. 2011UK

Psychologicalsupportfornursesonpae-diatricintensivecareunits

Qualitativere-search:casestudy

Nursesshouldbeentitledtoseeknumerouspsy-chologicalsupportwhendealingwithgrief,andit’sim-portantthatnurs-esacknowledgetheirfeelings.

Reid,F. 2013Scotland

Griefandtheexperiencesofnursesprovid-ingpalliativecaretochildrenandyoungpeo-pleathome

Qualitativere-search

Nursesrequireconsiderableskillsandreflectiontomanagetheirowncopingstrategies,inordertocon-tinuecaringforotherpatients.

Stayer,D.&LockhartJ.S.

2016USA

LivingwithDy-inginthePedi-atricIntensiveCareUnit:A

Qualitativere-search:herme-neuticphenome-nologicalstudy

Nursesfindpro-fessionalsatisfac-tioninprovidingpalliativecare,

42

NursingPer-spective

andusesupportfromcolleaguestocope.

Ångström-Brännström,C.,Dahlqvist,V.,Strand-berg,G.&Norberg,A.

2014Sweden

Descriptionsofcomfortinthesocialnetworkssurroundingadyingchild

Qualitativere-search:casestudy

Nursesgaincom-fortfromcol-leaguesandrela-tives,andfrommakingadiffer-encetothedyingchild.