The Proposal

1

A Perception: Knowledge, Attitude and Coping Mechanisms of Nurses Assigned in

Intensive Care Unit Towards death and Dying Patients

Introduction

End-of-life (EOL) care is defined as an active, compassionate approach that treats,

comforts, and supports persons who are living with, or dying from progressive or chronic life

threatening conditions. A 1999 report by the National Task Force on End-of-Life Care in

Managed Care recommended that the health care system take steps to enhance palliative pain

management care, knowledge and skills of medical and nursing leadership, and a recent study by

the Los Angeles-based City of Hope National Medical Center, a designated comprehensive

cancer center, found that more than half of 2,300 surveyed nurses consider their end-of-life

training inadequate.

In recent studies done by Lissi Hansen, RN, PhD, Teresa T. Goodell, et. al in 2009, they

Stated that nurses who work in Intensive Care Units (ICUs) have traditionally received little

education and training in care of dying patients. Furthermore, they also cited that Critical care

nurses lack knowledge about palliative care in general and in providing support to and

communicating with patients and patients’ families. End-of-life issues are poorly addressed, both

in nursing schools and healthcare institutions. There is no emphasis on the concerns or problems

encountered by the patient nearing death’s bed.

Being assigned in the Intensive Care Unit, Nurses are expected to have full knowledge on

concept about death and proper care for the dying. They were supposedly being more equipped

on establishing care for the patient and their family. Nurses should be concerned about providing

holistic care in relation not only to the physical and psychological needs, but also to the social

and spiritual needs of the dying in respect to his/ her faith. They should be adequately educated

and prepared for the provision of quality end-of life care. Health care providers are much better

at saving lives than helping patients know when life is at its end. Nurses perpetuate the myth that

not talking about death will keep it at arm's length. There is little evidence to suggest that

patients and their families are well informed about EOL issues, or about their options for

treatment and care. In a research done by White PJ; Urvash BP; Are Nurses Adequately Prepared

for End-of-Life Care, indicated a result that nurses most often selected discussion of the dying

2

process with patients and their families as the number one core competency about which they

would like to have had more education .

Nurses who work in Intensive Care Units (ICUs) have traditionally received little

education and training in care of dying patients and the patients’ families, even though death

often occurs in ICUs. Moreover, other factors that may be as important for providing end-of-life

care such as the attitude of nurses, work environment with strong communication and

collaboration between nurses and physicians, use of palliative care services, ready availability of

ethics consultations, and adequate support of patients, patients’ families, and staff should also be

given as much importance, since these factors contributes to the care established for dying

patients.

In most hospitals, end-of-life training is not usually mandatory for Nurse assigned in the

Intensive Care Unit. The SUPPORT Study (Study to Understand Prognosis and Preference for

Outcomes and Risk of Treatments) revealed that dying patients experience considerable

suffering and are victims of inappropriate use of medical resources. Critical care nurses are

acknowledged experts in physical care for critically ill patients. These nurses are certified in

various courses such as Advanced Cardiac Life Support and follow algorithms, protocols, and

procedures to stabilize patients’ conditions and treat the patients. However, few algorithms,

protocols, and procedures are available to guide the care of patients and patients’ families at the

end of life.

Statement of the Problem

GENERAL OBJECTIVE:

This study aims to determine the level of knowledge, attitude and the coping mechanisms

of nurses assigned in the Intensive Care Unit towards death and the dying patient.

SPECIFIC OBJECTIVES

Specifically, this study aims to:

1. Describe the demographic data of the respondents as to age, sex, civil status, educational

attainment and length of service.

3

2. Determine the level of knowledge of the respondents on death and the dying patients.

3. Determine the attitude of the respondents on death and the dying patient.

4. Determine the coping mechanisms of the respondents when faced with death and the

dying patient.

5. Determine if there is a significant relationship between age, sex, civil status, educational

attainment and length of service and the level of knowledge of the respondents on death

and dying patient.

6. Determine if there is a significant relationship between age, sex, civil status, educational

attainment and length of service and the attitude of the respondents on death and dying

patient.

7. Determine if there is a significant relationship between age, sex, civil status, educational

attainment and length of service and the coping mechanism of the respondents on death

and dying patient.

8. Determine if there is a significant relationship between the level of knowledge of

The respondents and their attitude towards death and the dying patient.

9. Determine if there is a significant relationship between the level of knowledge of

The respondents and their coping mechanism towards death and the dying.

10. Determine if there is a significant relationship between the attitude of the

respondents and their coping mechanism towards death and the dying patients.

Theoretical and Conceptual Framework

This study is anchored on the theory FROM NOVICE TO EXPERT by Patricia E.

Benner, which states that expert nurses develop skills and understanding of patient care over

time through a sound educational base as well as a multitude of experiences. She further explains

that the development of knowledge in applied disciplines such as medicine and nursing is

composed of the extension of practical knowledge (know how) through research and the

characterization and understanding of the "know how" of clinical experience.

The way that nurses cares for dying patients can be conceptualized as one aspect of

obtaining clinical knowledge. This knowledge is derived from personal and professional

4

experience that may differ from theoretical knowledge we get from studying at school. Past,

personal and professional experience may affect not only the care given to dying individuals but

also with the Nurse’s attitude towards death.

In this study, the level of knowledge on death and the dying patient serves as the

independent variable while coping mechanism and Attitude towards death served as the

intervening and dependent variables, respectively. The antecedent variables which are the

demographic profile of the respondents would greatly influence the level of knowledge obtained

from the death and the dying patient. With this, it could be assumed that as the nurse become

older or increased work experience could exhibit a high level of knowledge compared with the

newly registered nurses.

It can also be seen in this study, that coping mechanisms which is the intervening variable

could either increase or decrease the influence the level of knowledge and the attitude of nurses

towards dying patient.

ANTECEDENT INDEPENDENT INTERVIENING DEPENDENT

Figure 1. Interrelationship of the dependent and the independent variable

HYPOTHESES

Demographic profile:

Age

Sex

Civil Status

Educational Attainment

Length of service

Level of Knowledge on death and the dying patient

Attitudes towards death and the dying patient

Coping Mechanisms

5

1. There is no significant relationship between age, sex, civil status, and educational attainment,

length of service and the level of knowledge of death and the dying patient.

2. There is no significant relationship between age, sex, civil status, educational attainment,

length of service and the attitude of the respondents on death and dying patient.

3. There is no significant relationship between age, sex, civil status, educational attainment,

length of service and the coping mechanisms of the respondents on death and dying patient.

4. There is no significant relationship between the level of knowledge of the respondents and

their attitude towards death and the dying patient.

5. There is no significant relationship between the level of knowledge of the respondents and

their coping mechanism towards death and the dying.

6. There is no significant relationship between the attitude of the respondents and their coping

mechanism towards death and the dying patient.

Significance of the Study

This study will be conducted to know the knowledge, attitude and coping

mechanisms of Nurses assigned in Intensive Care Unit towards death and dying Patients. The

result of the study can be beneficial to the Nursing Service Office, ICU staff nurses, for the

administration and for the future researchers.

The results of the study can provide the hospital administrators, specifically the Nursing

Service Department with information that can be the basis of improvement in the over-all

delivery of care and with the efficiency of the nursing service.

Data obtained will provide ICU staff nurses with insights about their nurses’ profile, and

at the same time evaluate if they have well equipped knowledge, exhibits good attitude and have

good coping mechanism skills in terms of caring for their sick and dying patients.

The hospital administrator will learn from this study. The findings of this could serve as

benchmark information and they can improve their good relationship and being supportive to

their employee, furthermore, they can be able to evaluate the physical and emotional capacity of

their ICU nurses in terms of the way that they care for their dying patients.

6

The result of the study can help the future researchers since this could serve as reference

for researches of a similar nature.

Scope and Limitation

This study will be conducted on all Intensive Care Unit Departments of the four major

hospitals of the province. The respondents of the study are the staff nurses, volunteers and

trainee are not included.

Results obtained from the study were derived from nurses’ responses to the different

items in the questionnaire to include those that pertain to their personal characteristics,

knowledge, attitude and coping skills of nurses towards death and dying patients.

Review of Related Literature

The life of a person begins with birth and life ends with death, this is a fact in the process

of all human beings. Death is inevitable for all living beings (Haisfield- Wolfe, 1996) and, as

healthcare providers, nurses play a principle role in the care of dying individuals and their

families. Consequently, as stated by Rooda, Clements, & Jordan, 1999, the care that nurses

provide to terminal or dying patients may be affected by their own attitudes toward death.

Furthermore, it has served as determinants of attitudes toward death and dying and encompassed

not only cultural, societal, philosophical, and religious belief systems, but also personal and

cognitive frameworks from which individual attitudes toward death and dying are formulated

and interpreted. Therefore, nurses’ personal feelings also may influence how they cope with

dying patients.

ICU nurses are skilled professionals who are well- equipped and knowledgeable in the

delivery of care and in monitoring all patients in the Intensive Care Unit (ICU). They participates

in ongoing education such as lecture or seminars about caring for their patients, so that they can

further hone their skills in giving immediate attention on the needs of their patients. Inspite of

their capabilities, one of the difficult duty for an ICU nurse is to provide care to patients they

struggled to keep alive (Ciccarello, 2003). In a study done by Celik in 2004, Nurses may be

prepared to face the death of patients in the ICU, but still they are unprepared to give end of life

care. For in studies done by Martheler, 2005, providing this kind of care may also cause the

7

nurse to experience feelings of guilt and inadequacy. Furthermore, during this period, nurses

have to share in the grief of patients’ relatives as well as providing respectful and honourable

post-death care to their patients.

In this sense, nurses need to be aware of their own feelings and thoughts about death.

Nurses often react to a patient’s death by feeling inadequate, feeling they have failed or feel

nervous, laugh or cry or have uncertain feelings when they touch a patient because of their

culture, religious beliefs, previous experiences, or because the death was unexpected. However,

ICU nurses have to keep all the emotions they are experiencing under control and carry out both

their duty to care for the deceased patient’s body before taking it to the morgue as well as

helping the patient’s family cope with the feelings they are experiencing and supporting them in

completing necessary administrative procedures, such as completing the death related section of

discharge papers, discussing transplantation if appropriate, and having families sign for the

patient’s personal items.

Knowledge on Death and the Dying

Death is often referred to as “the final stage of growth.” Many think death is only the beginning;

a step to the next level, the next realm. Mosby’s medical, Nursing & Allied Health Dictionary

says Death is: The cessation of life as indicated by the absence of activity in the brain and central

nervous system, the cardiovascular system, and the respiratory system as observed and declared

by a physician. One of the major problems in understanding death in our culture is it is so

unfamiliar, and it causes a great fear in many people. Death is a strange new experience that

usually takes place in a hospital or nursing home, rather than part of our normal life function.

Nurses are very committed to life and health. The dying patient is a contradiction to a

nurse's commitment. Occasionally people in the medical field react to the dying person as if they

represent a failure in their care, or their skills. Although there is really nothing a human being

can do to stop the destiny/ process of another human being. We can help the dying patient and

their families in their final hours with our education and compassion.

FEARS AND FEELINGS OF DEATH:

8

The dying patient almost always fears the loss of control. All of a sudden they cannot

control their own fate; there choices to stop a bad habit or to take care of themselves is now

gone. They fear the farther loss of control as their disease progresses. Having to depend on others

and to become a burden to family and friends is very humiliating. Fear is something we all face,

first we fear our pending death and then when it comes we even fear it more. Many of us become

angry when someone we love dies or we get angry when we find out we are dying. Guilt; if

someone we love dies, we can always find something we did or did not do to them, or for them.

(So remember to be kind and always make up differences). Always say I love you when you can.

Many times we think we could have saved someone; or we find out we are dying from

something that we could have prevented such as lung cancer. Grief; An over whelming feeling.

This feeling is one of immeasurable heights. There is no emptiness that compares to that of grief

from the loss of someone you love.

CULTURES, REGIONS, AND RITES:

Americans practices and attitudes are very different from other cultures regarding death.

In some cultures the dying person is kept at home to die and then the family does the after care.

The body is prepared for burial. Some cultures believe that life after death is a place free of pain

and suffering, a place where there are no hardships. They also believe in a reunification with

loved ones. Many believe there will be punishment and suffering for sin after death. Others

believe there is no after life, they believe death is the end. There are also beliefs on the body

itself. Some religions believe the body keeps its physical form and many others believe the sprit

and soul leave the body and go on. Reincarnation is the belief that the sprit and or soul return in

another body, or life form. Many people strengthen their spiritual beliefs when they are dying,

even people who have had little or no beliefs, find some when the end is near. Many religions

have rites and rituals that are practiced during the dying process and at the time of death. Prayers,

blessings, and scriptures that are read.

In Vietnam, quality of life is more important than quantity; this is true because of their

belief in reincarnation. Deaths is at home and upon death the body is washed and wrapped in

clean white sheets, coins or jewelry are placed in the deceased mouth; this is believed to help the

9

soul with their encounters with God and the devil. Their burial is in a coffin in the ground. The

Chinese have an aversion to death; autopsy and burial are up to each individual. Euthanasia is

allowed. Donation of body parts is encouraged. The eldest son is responsible for all arrangements

of the deceased, after 7 years the body is resumed and then it is cremated, the urn is then reburied

in the tomb, and White clothes are worn for mourning. In India their need for a clear head needs

to be respected when they are dying. They believe in God’s will, and are unsure of this will if

they are under the influence of medications that alter their minds. Providing a time and place for

the family to pray is necessary, this helps them deal with stress and conflict. After death the

Hindu priest pours water into the deceased mouth. Hindus may prefer only family members

touch the body and do the entire post-mortem themselves. Blood transfusions, organ transplants,

and autopsies are all allowed. Cremation is preferred; reincarnation is a Hindu belief. American

Indians believe that the sprit does not leave the body for at least 72 hours, they will many times

place the body above the ground in the air and allow the sprit time to leave the deceased, at

which time the body is disposed of. The Catholic Religion believes in last rights, it is very

important to assist a dying person who feels a need for last rights to have a priest there ASAP.

The Catholic religion feels the need to repent all of their sins through the priest before they can

enter into heaven.

Whatever the culture or religious beliefs your dying patient may have it is a very big part

of the nurse’s role to provide this care. Again each person’s death is very individual, and we owe

it to our patient to give him or her it is they need to leave this world in whatever manor they

choose. If a request does not interfere with the health or safety of anyone else grant a dying

patient their last wishes. This can be as simply as seeing a long lost son or a dog or even visiting

a place, if it is possible, we must do the best we can to get it to happen.

THE STAGES OF LOSS:

Dr. Elisabeth Kubler- Ross described five stages of dying/ Loss:

Denial- this is usually the first stage, it may be revisited many times in the future, but

denial is our bodies’ first defense mechanism to death. People refuse to believe they are dying,

“No not I” is a very common response. There must be a mistake. This also happens when we lose

10

someone we love, “No not them," it is easier to deny it, then to feel the extreme pain of loss. This

person cannot deal with any problems or decision making at this time! This stage can last for

hours, days, or much longer.

Anger - This is usually the second stage but as with all the stages, there is NO set path to

follow when one is going though these stages. The person thinks “Why Me” This happens as the

patient accepts the fact it is happening, they are dying. This goes true also when we love some

we love, “Why them." People going through this stage may begin to resent those who have life.

Family, friends and health care workers are usually the targets of this patient's anger. It may be

hard for everyone involved to deal with this stage of dying. Try very hard not to take it personal.

Avoid any urge to attack back.

Bargaining- this is the third stage. Anger has passed (or it has left for a minute) and then

it is “OK it’s me but," or “if you let her live, I will” Often the bargain is with God for more

time. , Just one more Christmas. This stage may go unnoticed; it is many times done in private.

Depression- this is the fourth stage. “Yes Me,” or “Yes them," This is a very sad time.

This is a mourning stage, things that will be lost. There may be a lot of crying or no words at all.

Acceptance- person is calm, almost a sudden transformation may occur. There is a peace.

The words have been spoken; all that had to be done is done. The person is ready to accept death.

This doesn’t always mean they die soon after they enter this stage… With the loss of someone

else, acceptance is a hard place to get to, the person might accept the loss of their loved one and

then a trigger occurs and they go right back into anger, or depression, or even denial.

People do not follow a given or set path, they go in and out of the different stages, and

this is OK. People do not always go through all five stages, and they may never get beyond a

certain stage. Each person is an individual. Each individual need us to recognize there need to go

through whatever they need to go through for them.

NURSES ROLE and INTERVENTIONS:

11

To give the best care a nurse can give, they must have an understanding and spiritual

belief system within themselves about death. Death does matter, whether it may be a patient of

one day or a patient of one year, their death causes an effect. It is when we try to be that super

nurse, and pretend nothing bothers us, we get in trouble. You must deal with the deaths in your

life, or they will deal with you. A very important principal of nursing is all patients are equal and

individual, who deserve the best possible care we can give. Regardless of a person’s background

or illness. Unfortunately studies show that social values determine the way a dying person is

treated. Such as age, attractiveness, socioeconomic status, and former accomplishments. Many

times he nurse becomes the most important link with life for the dying person. Again this will

become a problem for the nurse if they do not deal with each and every loss as they come, and to

issue their own belief system.

PSYCHOLOGICAL, SOCIAL, AND SPIRITUAL NEEDS

The dying patient continues to have psychological, social, and spiritual needs. They may

want their family and friends present. They may want or need to talk out their fears, worries, and

desires. Some people might want to be alone, or they act as if they do, out of fear. Many patients

need to talk during the night; fears may increase at this time. One of the most important and most

rewarding skills a nurse can give to the dying patient is to LISTEN. Just LISTEN. The dying

person is the one who needs to talk, to express their feelings, and share their worries and

concerns. Just to be there to listen, nothing really needs to be said, and never worry about saying

the wrong thing, just talk from your heart.

Touch is also important; touch can convey caring and concern when words cannot.

Sometimes a person does not want to talk or they are afraid to share their fears, so just be near

for them. Silence, along with touch, is a very powerful nursing skill. Spiritual needs are

important. The dying person may wish to see a priest, rabbi, minister, or other clergy. The person

may also want to take part in some sort of religious practice. Privacy is necessary during prayer

time and spiritual moments. The dying person should be allowed to have religious items around

them, you need to respect their value to the patient. Many times I have had patients who want the

12

bible read to them. Please feel free to do this. I do not say you must practice or believe in their

faith, I merely ask you assist them in whatever way you can in their needs for a spiritual exit.

THE FAMILY is a very important part of this dying patient. Families consist of a lot of

different people, and the nurse is not the one to decide who is and is not family. Blood does not

always have to flow in a person’s vein to make them family. The patients' wishes must be

honored. We do not ask the family questions for a patient if the patient is able to answer for

themselves, this is even true of the patient's spouse.

PHYSICAL NEEDS OF THE DYING PATIENT:

Dying may take a few minutes, days or weeks. There is a general slowing down of the

bodies' processes as a person is dying. They become weak; levels of consciousness may change.

It is very important to allow the patient as much independence as possible. As they become

weaker or less responsive the nursing team will need to help with basic needs. As the death nears

the patient might become totally dependent on the nursing staff for all of their ADL’s. Every

effort is given to provide the best care, physically and psychological to a dying patient. This

person needs be allowed to die in comfort and with dignity.

VISION, HEARING and SPEECH- Vision may become blurred and gradually fail, this person

will automatically turn towards the light, a very dark room may frighten them. Keeping some

light in the room is important, but not real bright lights. The eyes may stay half-open, this will

cause dryness and accumulation of secretions in the corners, and frequent eye care is necessary.

Always talk to the patient and let them know you are there and keep some light in the room.

Hearing is the last sense to go, remember the patient can hear you even when you think there is

no way they could. So talk to them, continue to explain what you are doing and why, keep your

normal tone of voice, offer words of reassurance and comfort. Remember to never offer false

promises.

MOUTH, NOSE and SKIN. A dying person’s mouth many times become very dry and

their lips crack. Mouth care is important and needs to be done frequently with glycerin swabs, or

toothettes. You do not want to put a lot of water, or fluids in the dying person's mouth. Many

13

times they are unable to swallow and too much fluid can cause them to aspirate. When giving

mouth care always have the head of the bed up and their heads turned to the side. Part of mouth

care is applying lubricant to the patients' lips. The nostrils may become dry or crusted from

drainage or oxygen, assess these areas frequently.

CIRCULATION decreases and then fails. Body temperature may increase as death

approaches. Even though the body temperature goes up the skin becomes cool, pale, and mottled.

Perspiration increases, many times profusely. Good skin care, bathing, and prevention of

decubitus ulcers are very important nursing measures. Positioning the patient frequently and

keeping them comfortable as possible, you may use pillows to help with positioning and to avoid

skin to skin contact.

ELIMINATION- the dying person may become incontinent of bowel and bladder. Bed

protectors or attends may be needed. Perineal care is very important.

THE RIGHT TO DIE:

There are legal issues involved in dying. The right to die. Many people do not want to be

kept alive by machines or other measures. Consent must be given to do any treatment on a

patient. If the patient is not able to do so, the nearest living relative will be asked. People need to

make their own decisions while they are able.

A person the right to accept or refuse medical treatment. They also have a right to make

advance directives (a written document stating a person’s wishes about health care when the

stated person is unable to do so for themselves). Living will (a person’s written statement about

the use of life-sustaining measures, feeding tubes, ventilators, and CPR are a few). Durable

power of attorney (the power to make decision about health care is given to another person,

family or friend, or sometimes a lawyer) These are common forms of advance directives.

Do Not Resuscitate Order. When death is sudden and unexpected, every effort to save life

is given. CPR and any and all emergency treatment is given to sustain a person life. Things are

different with a long term or chronic illness, the patient has a right to have their doctor write a

14

“No Code," or Do Not Resuscitate DNR order. This means that no attempts will be made to

resuscitate a terminally ill person. The person is allowed to die in peace and with dignity. The

orders should only be written after the MD speaks with the patient and then with the family,

significant others.

SIGNS OF DEATH:

Signs of death may happen suddenly or they may happen slowly.

Movement, sensation and muscle tone are lost. This most often starts in the feet and legs

and then spreads all over the body. The mouth muscles relax, the jaw may drop, and the mouth

may stay open. Peristalsis and other GI functions slow down; there may be distention of the

abdomen, fecal incontinence, impaction, and nausea, vomiting (many times bile, stomach acid).

Circulation fails, body temperature rises. The person may feel cool or even cold, they may be

very pale or gray in color, and perspiration increases. The distal extremities become cyanotic,

this gradually grows up from the toes and fingers. The lips may also become blue in color. The

pulse becomes very fast, weak and irregular. Sometimes you may find it hard to even find a

pulse. The respiratory system fails. Cheyne stokes, slow, or rapid and shallow respirations are

observed. Fluids back up and they become very wet, this causes the “the death rattle." Pain

decreases as the person loses consciousness and or dehydrated. Confirmation of death will show

that the patient has no pulse, respiration, blood pressure and fixed and dilated pupils.

POST MORTEM CARE:

The nursing staffs gives post mortem care, if it is you first time, do not do this alone. This

care begins when the person has been pronounced dead. Remember always to exercise the

universal precaution.

Post mortem care is done to clean the patient's body and maintain their appearance.

Remember to always give dignity to the patient. Keep them covered as you would if they were

still alive, talk t them as you complete your work, many times this helps the nurse release some

of her tensions. You need to get the body ready and looking as nicely as you can before the

15

family comes to see them. Remember death is a very difficult time for all involved, be kind and

compassionate.

Within 2-4 hours after death rigor mortis (stiffness or rigidity) sets in on the skeletal

muscles. Post mortem care includes positioning the patient in a normal position as soon as

possible. Many times movement of the body can cause air that is trapped within the body to be

expelled, through the mouth or anus, do not let these sounds scare you, they are normal and

happen frequently. Post mortem care also involves gathering all personal items for the family

and or the mortuary, (the mortuary might want the dentures and anything else that may be

needed for the body). Make sure any and all things that are taken are signed off the property

sheet. Always remember a person’s body (their form) leaves this earth when they die (ashes to

ashes) but no one can take away their essence, we are but a thought and thought never dies.

Attitudes Towards Care for the Dying

Dying is the final portion of the life cycle for all of us. Providing excellent, humane care

to patients near the end of life, when curative means are either no longer possible or, no longer

desired by the patient, is an essential part of nursing and medicine. The American Geriatrics To

provide quality care at the end of life, nurses must not only possess the knowledge and skills to

provide effective end-of-life care, but must also develop the attitudes and interpersonal

competence to provide compassionate care.

Nurses often care for patients in all stages of disease, from diagnosis to death or

survivorship. A nurse's caseload in a shift can consist of patients in varying phases of illness,

presenting a challenge to nurses who must constantly adjust to the different needs of each patient

and their families. The attitudes of nurses toward death and dying patients may influence the care

nurses are able to provide although a systematic investigation of the variables that are important

in providing effective care for the dying has not been conducted, the variables of death anxiety

and attitudes toward death and dying have been identified within the clinical literature as being

significant. Nurses who are anxious in relation to death and have negative attitudes toward death

are described as retreating from dying patients and therefore unable to provide effective care.

Ideal positive attitudes to care of the dying are defined as flexibility in interpersonal

relations, desire for open communication about critical issues, and psychological mindedness in

16

relation to patients and families of dying patients. Caring for an individual with a terminal illness

requires great ski11 and understanding on the part of nurses. The characteristics of the nurse as a

person are critical in the establishment of nurse’s attitudes towards care of the dying patients.

How nurses feel about caring for persons with a terminal illness will depend, to a large extent, on

the nurses' feelings and ideas about death and dying, their religious convictions, and their

philosophies of death and life.

Lev (1986) refers to attitudes as a pattern of views reflecting cumulative prior perceptions

and experiences which includes cognitive, affective and behavioral components. The cognitive

component adopts the premise of a human's need for balance, symmetry or reduced dissonance.

In striving to achieve consistency attitudes may undergo change. The second aspect of attitudes

is the affective component. Positive or negative tendencies toward the object may result in

seeking versus avoiding and liking versus disliking. Positive affective tendencies may account

for those nurses who feel comfortable around dying persons. Negative affective tendencies may

account for those nurses who feel disengaged from dying patients and emotionally withdraw.

Finally, the behavioral component is the action taken by the individual, either seeking palliative

care work or avoiding the context altogether Several studies indicated the factors that influence

the attitudes of nurses' toward dying patients such as gender, age, personal background,

socioeconomic status, religion, family openness, level of education and recent death experiences

of family members and friends all these factors affect on the nurses' attitude. The scientific

education of the nurses also affect on her attitude. These studies noted that more experience leads

to less anxiety about dying and positive attitudes toward caring. Many studies have shown that

improvements in formal education can aid practitioners to cope with death. They mentioned that

participants in a death education course showed a clear decline in negative attitudes.

Changes in the causes of death and advances in medical technology are leading nurses

today to become more involved with end-of-life care than previously. Yet, terminally ill patients

and their families have reported dissatisfaction with end-of-life care. One reason for the

dissatisfaction may be attitudes among nurses about end-of-life care. Attitudes about end of life

affect nurses' ability to care for and communicate with patients and families facing these issues.

For this reason, it is important to examine nurses' attitudes about end-of-life care, to improve

care to patients and families facing death.

17

Stress and Support of Nurses

In the study done by the American Journal of Critical Care, it can be gathered that issues

related to end-of-life care and decision making have led critical care nurses to describe feelings

such as stress, frustration, anger, sadness, helplessness, and moral distress. Moral distress is

associated with an inability of nurses to influence end-of-life decisions and decision-making

processes, aggressive care provided to patients who are not benefiting from such care, and

conflicts within patients’ families and the families’ indecisiveness about terminating treatments.

Moral distress also has been associated with nurses’ inability to take the correct course of action

because of institutional constraints. Moral distress is a serious problem for nurses who practice in

ICUs, not just when providing end-of- life care to patients and patients’ families, but in general.

Such distress may lead to burnout, job dissatisfaction, and leaving the work environment. In one

study, critical care nurses reported that moral distress affected their job satisfaction, physical and

psychological well- being, self-image, spirituality, and decisions about their own health.

Although it has been defined as 1 of 7 quality end-of-life care domains to be used in

ICUs, little is known about the domain of emotional and organizational support for critical care

staff. The domain may include support during the time staff provide care to dying patients and

the patients’ families before and after the patients’ death and may include formal and informal

mechanisms such as having a staff counsellor, team meetings, debriefing sessions, peer support,

and in-service sessions related to end-of- life care, loss, and grief. Provision of ongoing

emotional and critical feedback to colleagues who are caring for dying patients and the patients’

families when the feedback is needed, rather than at specific scheduled meetings, is important to

critical care nurses. However, formal scheduled debriefing sessions are also a need, particularly

after life support has been withdrawn from patients. In a survey of critical care nurses, Puntillo,

et.al, found that unit-level meetings that focused on grief counselling and debriefing of staff after

a patient had died rarely or never occurred. Kirchhoff et. al. concluded in their study of critical

care nurses’ experiences with end-of-life care that staff support through education about and

resources for end-of-life care would improve care of dying patients and their families.

18

Care For the Dying patient and the Family

When it is not possible to prevent a patient dying, and medical care is no longer possible

or useful, the nurse provides supportive care to the patient and family. The main goals are to:

· keep the patient comfortable and free of pain

· make the patient's final days as good as possible for both patient and family, with as

little suffering as possible

· help the patient to die peacefully

· provide comfort to the family.

It is important for nurses who care for the dying to be aware of their own feelings about

death and about their patients. It is difficult to see people die who you have cared for. It is

especially difficult if a child or young person dies. You have not only cared for them, you have

also cared about them. Many nurses feel frustration and grief when their patients die. It is

important for you to recognize those feelings. You need to comfort and support each other in

your care of the dying. And must be sensitive to their needs like:

Relieving the dying person's pain.

Keeping the patient comfortable.

Helping giving the patient a peaceful death.

Care after death.

Coping with Death and the Dying

According to Allison Palmer, R.N., the nurse who experiences the loss of a patient can go

through many emotional responses.  These responses can be magnified for those who deal more

closely with death and dying. The nurse experiences loss in working with the dying and their

families. Grief is the emotional response to these losses and needs to be expressed in order to

facilitate adaptive coping.  The nurse may experience feelings of anxiety and grief as well as

cumulative loss when he or she is unable to cope effectively with each loss.   Ineffective coping

mechanisms may include avoidance and emotional distance.  Additional stressors may result

from circumstances requiring the nurse to either withhold or express personal emotions

appropriately and portray empathy toward the patient and family.  Losses may be compounded

beyond the aspects of the death of a patient.  It may include the loss of a close relationship with

19

the patient, losses of professional boundaries and unmet goals and expectations.  The nurse may

also experience a compromised personal belief system or assumptions about death that make it

difficult to overcome a loss.

Coping Mechanisms

Coping mechanisms can be described as the sum total of ways in which we deal with

minor to major stress and trauma. Some of these processes are unconscious ones, others are

learned behavior, and still others are skills we consciously master in order to reduce stress, or

other intense emotions like depression. Not all coping mechanisms are equally beneficial, and

some can actually be very detrimental. The body has an interior set of coping mechanisms for

encountering stress. This includes the fight/flight reaction to high stress or trauma. A person

perceiving stress has an automatic boost in adrenaline, prompting either action, or inaction.

People have a variable level of physical reaction to different levels of stress. For some, merely

getting interrupted from a task can cause an inappropriate fight/flight reaction. This can translate

to “fight” mechanisms, where a person gets very angry with others for interrupting him.

Alternately, flight may include physically leaving, or simply being unable to regain focus and get

back on task.

Coping

Coping 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." Coping activities may be problem-focused in that they are directed

externally and involve attempts to manage or change the problem causing the stress. On the other

hand, coping activities may be emotion-focused in that they are internally directed and involve

attempts to alleviate emotional distress. Examples of problem-focused coping includes problem-

solving activities, recognizing one's role in solving a problem and confronting the situation by

using some degree of risk-taking behavior; while emotion-focused coping includes wishful

thinking, avoidance of confrontive behavior, and detachment or disengagement from the

situation. According to Lazarus and Folkman, individuals use both problem-focused and

emotion-focused coping when dealing with stressful situations. Lazarus and Folkman have

20

identified and described eight coping strategies people use to contend with stress. These

strategies tend to be either problem-focused or emotion-focused in nature. The eight strategies

include: confrontive coping, distancing, self-control, seeking social support, accepting

responsibility, escape-avoidance, planful problem-solving and positive reappraisal. Confrontive

coping is described as aggressive efforts to alter a situation that involve using some degree of

hostility and risk-taking behavior. Distancing is disengagement or detachment from a situation in

an attempt to minimize the significance of the situation. Self-control involves efforts to regulate

one's feelings and actions. Seeking social support involves efforts used to obtain informational,

tangible and/or emotional support from others. Recognizing one's role in solving a problem

describes accepting responsibility. Wishful thinking and behavioral efforts to avoid confronting a

problem or stressful situation describes escape-avoidance. Planful problem solving involves

efforts to alter the situation, including an analytic approach. Finally, positive reappraisal is

described as a spiritual dimension that includes giving positive meaning to a situation by

focusing on one' personal growth experience.

Coping strategies found to be most effective in dealing with nurses' workplace stressors

of interest is how nurses cope with workplace stressors based upon country of origin. In a series

of research studies involving hospital nurses, it was found that although nurses identified the top

two stressors (death and dying issues and workload) to be the same, regardless of country, there

were variations in coping methods. Lambert et al. and Cheng et al. found the three most

commonly used coping strategies, in descending order of preference were: planful problem-

solving, self-control, and seeking social support for Australian nurses; positive reappraisal, self-

control, and planful problem-solving for Chinese nurses; self-control, seeking social support, and

planful problem-solving for Japanese nurses; planful problem-solving, self-control, and seeking

social support for New Zealand nurses; positive reappraisal, self-control, and seeking social

support for South Korean nurses; self-control, planful problem-solving, and positive reappraisal

for Thai nurses; and planful problem-solving, self-control, and positive reappraisal for USA

(Hawaii) nurses. Thus, it can be seen that nurses, regardless of country, tended to prefer planful

problem-solving, seeking social support, self-control, and positive reappraisal as coping

strategies in the workplace. Some research has suggested coping strategies that are more

21

problem-focused, rather than emotion-focused, tend to be associated with better mental health

when dealing with workplace stress.

Methods for Fostering Effective Coping Strategies

It is not possible to exist in a totally stress free environment. Regardless of how much one

might want to be completely free from stress, one has to contend with some level of stress

everyday in most situations. Given this fact, listed below are some stress management activities

suggests that might prove useful:

1. Avoid unnecessary stress. It is not possible to avoid all stressful situations, but one needs

to look at the number of stressors in life that can be eliminated.

Learn how to say “No”.

Avoid stress producing people

Avoid controversial topics

Take control of the environment

2. Alter the situation. If it is not possible to avoid a certain stressful situation, then work to

alter it. This may involve changing communication patterns or the manner in which daily

life is operated.

Be willing to compromise

Be assertive

Manage time better

3. Accept the things you cannot change. Some sources of stress are unavoidable.

Do not try to control the uncontrollable

Look for the positive side of the situation

Learn to forgive

22

4. Adapt to the stressor. If the stressor cannot be changed then regain a sense of control by

changing expectations and attitudes.

Reframe problems

Look at the big picture

Adjust your standards

5. Take care of personal needs. Make healthy lifestyle choices. Take time for rest and

relaxation. Nurturing ones' self is not a luxury, but a necessity.

Set aside relaxation time

Connect with others

Do something every day that is enjoyable

Keep a sense of humor

Exercise regularly and eat healthy

Avoid alcohol, smoking and drugs

Keep in mind no one solution for dealing with stress works for everyone. No single

method works for every situation, so one has to experiment with different strategies and focus on

what fosters control and calm.

Methodology

Research Design

The descriptive co-relational one shot survey method of research was employed in this

study. This research design was chosen with great emphasis on any ethical issues that may arise

and in order to maintain the integrity and reliability of the respondent’s responses. In descriptive

research, information is collected from the group of people to describe some aspects or

characteristics such as their opinions and attitudes. Co-relational research, on the other hand,

investigates the possibility of relationship between two variables. It involves collecting data to

23

determine whether, and to what degree, a relationship exists between two or more quantifiable

variables( Gay & Airasian, 2003).

The Study Population

The respondents of the study were the 35 Intensive Care Unit staff nurse employed at the

four major hospitals of the province. These are the nurses who were probationary hired on

contractual basis and nurses employed on regular status.

The Research Instrument

The instrument used in this study are a research-made questionnaire.

Part I includes items which required information about personal profile of the

respondents, particularly age, sex, civil status, educational attainment and length of service.

Part II are the statements regarding the knowledge of the respondents on death and care

for the dying patients. This will be measured by a 10-items questionnaire. A three-column

response category namely of “True”, “False” and “Not Sure” responses are included, then the

respondents were asked to tick their individual response to each items.

Part III is a 15-items questionnaire related to the attitudes of ICU nurses towards death

and caring for their dying patients. A five column response categories namely of “strongly

agree”, “Agree”, “Not Sure/ Mixed”, “Disagree” and “Strongly Disagree” are included, then the

respondents were asked to tick their individual response to each items.

Part IV is a 10-items questionnaires related to the coping capacity of Nurses assigned in

ICU. A five column response categories namely of “Always”, “Often”, “Sometimes”, “Seldom”

and “Never” are included, then the respondents are instructed to check their individual responses.

Validity and Reliability of Instrument

To ensure validity and consistency of instrument questionnaires the researcher will seek

consultations and comments from the professor of the research study. The valuable comments

24

and suggestions obtained like rephrasing some sentences in the situation making them direct and

simple, changing some of the choices since they mean almost the same with other categories, and

suggestions on common situations particularly significant to any institution can help greatly in

the improvement of the questionnaire.

A letter of permission was sent to the four major hospitals of the province through their

Nursing Service Director and Chief Nurse. The letter will state the title and the purpose of the

study. Upon approval of the request the researchers will deliver the questionnaires to the

respondents.

Data Gathering and Processing

After all the questionnaires were retrieved, the researcher will encode the data, enter the

codes in a data sheet prepared for the purpose. Then after all the data have been coded, they will

be encoded and subjected to statistical analysis using the Statistical Package for Social Sciences

(SPSS) PC software

Statistical Interpretation

Frequency distribution was used for the description of the personal profile of the

respondents such as age, sex and civil status, and length of service and educational status. To

determine the respondent’s level of knowledge, attitude and coping mechanism, the Gamma test

will be employed to test the significance of relationship between ordinal values and Pearson Chi-

square test was used to test the significant relationship between nominal and ordinal variables.

The alpha level of significance adopted for all inferential tests was set at 0.05 levels.

Statistical results were all computer generated.

References

Nurses' workplace stressors and coping strategies by Allison Palmer Copyright 2008- American Society of Registered Nurses (ASRN.ORG)

American Association of Nurse Anesthetists Journal

Assessing Coping Strategies: A theoretically Based Approach by Journal of Personality and Social Psychology copyright 1989

25

The measurement of coping with stress: Construct validity of the ways ofcoping checklist and the cybernetic coping scaleJeffrey R. Edwardsa; A. J. Baglioni Jra

Kubler-Ross, Elisabeth., On Death and Dying. Scribner (1997)

Despelder, Lynne, Ann., and Strickland, Albert, Lee., The Last Dance: Encountering Death and Dying. WCB/Mcgraw Hill Pub. (2001)

Scanlon, Valerie C., and Sansers Tina, Understanding Human Structure and Function. F.A. Davis Company (1996)

Anderson, Kenneth, N., Editor Mosby’s Medical, Nursing, and Allied Health Dictionary. A Harcourt Health Sciences Company. (1998)

ICU Nurses’ Experience in Caring for Dying PatientsAuthors: Orapan Chaipetch, Kittikorn Nilmanat, Wipavee Kong-in

Schedule Of Activity:

January 2012 – Execution of the Research

Appendixes

Part I. SOCIO DEMOGRAPHIC PROFILEInstruction: Kindly answer the questions or check the applicable items.Name: _________________________________________ (optional)Age: __________________ (as of last birthday)

Gender: ( ) Male

( ) Female

Civil Status: ( ) Single/Separated/Widowed/

( ) Married

Length of Service: ( ) 2 years and below

( ) Above 2 years

Educational Attainment: ( ) BSN

( ) BSN with MAN units

( ) BSN, MAN/MN

26

Part II: KNOWLEDGE ON DEATH AND CARE FOR THE DYING

Instruction: Kindly read each questions carefully and check the appropriate box of your

best answer.

QUESTION TRUE FALSE NOT

SURE

1. Death is unique to each person

2. Death is the cessation of life as indicated by the absence of

activity in the brain and central nervous system

3. A dying patient deserves respectful, gentle nursing care.

4. To promote healing in those who are ill and to ease the

suffering of dying patients is one of the basic reponsibilities of

a Nurse.

5. Grief is the emotional response to a loss, experienced by a

person as grieving.

6. Medicines and other supportive care may be given to

decrease a dying person’s pain and other symptoms

27

7. Death is the cessation of life as indicated by the absence of

activity in the brain and central nervous system

8. It is good to give dying patients reassurance to the extent of

lying, just to alleviate their feelings.

9. Depression is one of the psychological reactions to death

and dying.

10. A person needs be allowed to die in comfort and with

dignity.

Part III: ATTITUDE ON CARING FOR THE DYING PATIENT

Instruction: Please indicate how much you agree or disagree with each following statements by

checking the box under the statements that best describes your feeling: Strongly agree, agree, not sure

or mixed, disagree and strongly disagree. There are no right or wrong answers, just check the box that

best describes your feelings.

QUESTION Strongly

Agree

Agree Not

sure/

Mixed

Disagree Strongly

Disagree

1. Giving nursing care to the dying

person is a worthwhile learning

experience.

2. Death is not the worst thing that can

happen to a person.

3. I would waaant to be assigned to care

for a dying person.

4. Nursing care for the patient’s family

should continue throughout the period of

28

grief and bereavement.

5. It is difficult to form a close

relationship with the family of a dying

person.

6. I am afraid to become friends with a

dying patient.

7. It is possible for nurses to help

patients prepare for death.

8. Dying people should be given honest

answers about their condition.

9. It is beneficial for a dying person to

verbalize his feelings.

10. The dying person should not be

allowed to make decisions about his or

her physical care.

11. Nursing care should extend to the

family of the dying person.

12. Educating families about death and

dying is not a nursing responsibility.

13. The family should not be involved in

physical care of the dying person.

14. Nurses should permit dying people to

have flexible visiting schedules.

15. Family members who stay close to a

dying person often interfere with the

29

Nurse’s job with the patient.

Part IV: COPING MECHANISM OF NURSES

Instruction: Kindly check the appropriate box that is related to your choice.

Code: 5 – Always, 4– Often, 3- Sometimes, 2- Seldom, 1 – Never

QUESTION 5 4 3 2 1

1. I take additional action to try to

get rid of the problem .

2. I concentrate my effort on doing

something about the problem.

3. I do what has to be done, one step

at a time.

4. I take direct action to get around

the problem.

5. I make sure not to make matters

worse by acting too soon.

6. I look in something bad for what is

happening.

7. I get upset and let my emotions

out.

30

8. I try to pretend that I had not

happened.

9. I give up the attempt to get what I

want.

10. I admit to myself to myself that I

can’t deal with it and try quitting.

11. I sleep more than usual.

12. I drink alcohol or take drugs in

order to think about it less.

31

.