Working Through Grief and Loss: Oncology Nurses' Perspectives on Professional Bereavement

Jennifer Wenzel, PhD, RN, CCM; Maya Shaha, PhD, RN; Rachel Klimmek, BS, RN, OCN®; Sharon Krumm, PhD, RN

Disclosures

Oncol Nurs Forum. 2011;38(4):E272-282. 

In This Article

Abstract and Introduction

Abstract

Purpose/Objectives: To determine facilitators and barriers to managing patient loss from the combined perspectives of oncology nurses and to extract essential components of a supportive intervention.
Research Approach: Qualitative, descriptive.
Setting: The comprehensive National Cancer Institute–designated cancer center of a mid-Atlantic university teaching hospital.
Participants: 34 nurses from inpatient and outpatient adult and pediatric oncology units.
Methodologic Approach: Focus groups were held with oncology staff nurses to identify challenges regarding work-related bereavement, current support for managing grief and loss, and how to support interpersonal functioning and resiliency.
Main Research Variables: Work-related bereavement, bereavement support, and interventions and management strategies for bereavement and loss.
Findings: Two primary themes emerged: dimensions of work-related loss and working through bereavement. Participants also provided many concrete suggestions for the creation of a supportive self-care environment.
Conclusions: Support issues were numerous, multilevel, and varied. However, addressing those concerns can improve job satisfaction and decrease compassion fatigue. The findings lay the foundation for appropriate interventions to assist nurses in managing those situations.
Interpretation: Administrators, managers, and individuals interested in furthering the multifaceted goals of oncology care, including nurses themselves, are challenged to create and maintain mutually supportive environments for providing optimal care to patients and families.

Introduction

The global demand for highly skilled, experienced oncology nurses continues to grow because of increased disease incidence and improved cancer survivorship. However, predicted oncology workforce shortages may negatively affect both the quantity and quality of cancer care, including related areas such as research, healthcare access, and survivorship in the 21st century. To date, staff and faculty shortages have decreased the number of nurses receiving specialized oncology education and training (Institute of Medicine, 2009).

In spite of growing evidence that experienced oncology nurses contribute to high-quality cancer care and improved patient outcomes, administrators in oncology settings commonly face multiple challenges to nurse retention, including inadequate staffing levels, high patient acuity requiring complex care delivery, and long work hours (Buerhaus, Donelan, DesRoches, Lamkin, & Mallory, 2001). Caring relationships fostered by oncology nurses also may be associated with emotional burden (Showalter, 2010; Walton & Alvarez, 2010; Yoder, 2010) that can be exacerbated by increased workloads, heightened client acuity and complexity, and repeated contacts with patients who are suffering. This burden may become overwhelming during situations in which nurses lack experience, skills, or sufficient professional and social support to manage their own psychological health (Sabo, 2008). Nurses providing care to patients who are suffering or actively dying also may experience trust issues, loss of independence, and decreased capacity for intimacy, as well as loss of control (Figley, 1995), anxiety, anger, and irritability (Lerias & Byrne, 2003). Stressful events experienced by nurses caring for patients in life-threatening situations also can lead to intrusive imagery, defined as "fragments of specific autobiographical events or imaginal extensions of such events that predominantly possess sensory qualities and enter awareness suddenly and unintentionally" (Boelen & Huntjens, 2008, p. 217). Therefore, nurses may relive and re-experience traumatic events repeatedly in their minds. Those psychological disturbances can have personal and professional consequences (Sabo, 2008). Responsibility for delivering therapies that may increase symptoms or negatively affect patients' quality of life, even temporarily, also can increase stress for nurses and may lead to feelings of powerlessness, helplessness, and hopelessness (Abendroth & Flannery, 2006; Byrne & McMurray, 1997; Medland, Howard-Ruben, & Whitaker, 2004).

Experienced, professional oncology nurses contribute significantly to patients' well-being and clinical outcomes, in addition to advancing the art and science of oncology nursing. Replacing those nurses during situations in which they are unable to remain in either their specialty or institution is extremely difficult and requires significant amounts of time, effort, and financial resources. Therefore, a better understanding of bereavement and sources of support to bolster individual and communal coping with acute and chronic loss may be important factors in reducing care fatigue and retaining experienced oncology nurses.

Important tasks for nurses who care for dying patients include understanding the process related to bereavement and effective assessment of social support for themselves and for patients and families (Medland et al., 2004). Oncology nurses must be skilled in those tasks while also coping positively with all bereavement-related issues (Medland et al., 2004). Dorz, Novara, Sica, and Sanavio (2003) reported higher emotional exhaustion levels among oncology staff than in those caring for patients with HIV or AIDS. For nursing staff, the difficulty of providing care to dying patients is exacerbated by current and projected increases in the aging population and the fact that extensive care is provided to patients and families at the end of life (Ferrucci et al., 2003; Given & Sherwood, 2006; Vincent & Velkoff, 2010).

Prior research has demonstrated that nurses should be aware of the effects their work can have on their own health, as well as the health of their patients (Byrne & McMurray, 1997). Adverse effects on health have been noted among care providers working with patients at the end of life, but little is known about this work in relationship to the psychosocial health and well-being of nurses (Sabo, 2008). Lack of support during periods of this type of job-induced stress has been shown to lead to psychological distress (AbuAlRub, 2004). Concepts such as compassion fatigue and burnout also have been used to describe those phenomena in the literature, although factors distinguishing compassion fatigue from burnout remain controversial (Aycock & Boyle, 2009). Compassion fatigue is defined as a severe malaise that results from caring for patients who are in pain or suffering (Sabo, 2006). Maslach, Shaufeli, and Leiter (2001) defined burnout as a prolonged response to chronic physical or emotional stressors that results in exhaustion and ineffectiveness. Although other similar concepts with overlapping definitions also have been used in the literature, compassion fatigue most closely reflects the experiences of oncology nurses (Aycock & Boyle, 2009). In those instances, increased absenteeism, loss of productivity, and the choice to leave the workplace (or the specialty of oncology nursing altogether) may occur (Medland et al., 2004). Subsequent losses to institutions, patients, families, and the future of the specialty have been noted (Abendroth & Flannery, 2006). Conversely, a supportive environment, coupled with an understanding of how to recognize and properly manage personal bereavement, can assist nurses to avoid early burnout (Dorz et al., 2003) and compassion fatigue (Abendroth & Flannery, 2006). When supported in time-sensitive and helpful ways, nurses can create a culture of wellness and self-respect that gives them a wider range of interpersonal functioning and greater resiliency.

At the mid-Atlantic university teaching hospital where the current study was conducted, the turnover rate of oncology nurses had been increasing steadily from 13.3% in 2001 to 16.7% in 2004. The use of agency nurses to fill vacant positions over prolonged periods of time had become standard practice for the gynecology-oncology inpatient unit. Nursing administration at the hospital was aware of the fact that staff expended significant physical and emotional energy in caring for their patients. Administrators also were aware that nurses experienced acute or latent feelings of loss, grief, or a perceived loss of meaning in situations with undesirable outcomes including, but not exclusive to, death.

The hospital staff understood that strategies to assist oncology nurses in managing the stress of work-related bereavement should be tailored to specific work settings, and a need existed to explore factors to build resilience among nurses at risk for compassion fatigue (Sabo, 2008). Therefore, administrators, nursing staff, and faculty from the university teaching hospital's National Cancer Institute–designated comprehensive cancer center and the affiliated school of nursing collaborated on a study designed to inform a planned program of support for oncology nurses encountering situations involving bereavement and loss. The current study was designed using focus groups to identify issues surrounding work-related bereavement, characterize current support, and elicit participant suggestions for supportive interventions for managing bereavement and loss.

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