Effects of patient death on nursing staff: a literature review

WILSON, Janet and KIRSHBAUM, Marilyn

This document is the author deposited version. You are advised to consult the
publisher's version if you wish to cite from it.
Published version
WILSON, Janet and KIRSHBAUM, Marilyn (2011). Effects of patient death on
nursing staff: a literature review. British journal of nursing, 20 (9), 559-563.

Copyright and re-use policy

Sheffield Hallam University Research Archive

Background:

There were 509,090 deaths recorded in England and Wales for 2008 (ONS, 2010).

Of these numbers over 56% (260,000) occurred in National Health Service Hospitals,

This shows the large numbers of people dying each year in hospitals. The death of a

patient is an event which most if not all nursing staff will encounter during their work.

This experience can elicit physical, cognitive, behavioural, spiritual and emotional

responses (Parkes, 1998).

Aim:

The aim of this literature review is to explore how the death of patients in a hospital

setting impact on nursing staff.

Methodology:

A review of the literature was undertaken using the online databases CINAHL,

Medline and PsychInfo. The search was limited to articles in the English language

and those from peer reviewed journals.

Results:

Themes arising from the literature review were: the theoretical context, the emotional

impact, the culture of the healthcare setting, staff's previous life experiences and

support available for healthcare staff.

Conclusions:

The death of patients does have an impact on nurses. This can affect them both in

their work environment and outside of work. Education around grief theory and

support from others are helpful for staff in developing strategies for coping with

patient deaths.

1
Key Words: staff grief, psychosocial factors and patient death, emotional support and

staff and death

The effects of patient death on nursing staff: a literature review

Over 260,000 patients die in National Health Service (NHS) hospitals each year in

England and Wales. This is 56% of the total number of deaths recorded in 2008 and

is in contrast to 16% of people who die at home, 9% who die in hospices, and 18%

who die in community establishments (Office for National Statistics,2010).

It is acknowledged that the death of someone known to an individual has an impact

on the person experiencing the bereavement. (Kubler-Ross 1973, Parkes, 1975).

There has been research over many years identifying the impact of bereavement on

individuals. This has developed from Freud (1949) with his work on melancholia

through to recent theorists who have identified the importance of making sense of

the death (Neimeyer, 2001). A way of doing this involves the bereaved person

creating a story enabling them to integrate the memory of the dead person into their

ongoing life (Walters 1996).

Nurses are identified as having more extensive contact with patients than any other

healthcare professionals (Costello, 2001). In some areas of acute care in hospital

settings patients will have several episodes of hospital admissions or prolonged

stays in hospital. This will enable them and their families to become known to both

nursing and other healthcare staff.

The importance of this review is to identify if there are responses from nursing staff

which may have a detrimental impact on their lives at work or home and to identify

any support mechanisms which may be helpful.

2
The question which formed the basis for this search is, how does the death of a

patient impact on nursing staff and what support do they find helpful?

Search Strategy

The existing literature published on this topic was systematically searched for using

three main databases. The databases selected were the Current Index of Nursing

and Allied Health Literature (CINAHL), Medline and PsychInfo. Together these

three databases were thought to provide access to a wide range of texts which could

be relevant to this subject. Other sources of literature were sought from reference

lists contained in articles obtained from these three databases. The following

inclusion criteria were used in selecting articles; peer reviewed articles from

professional journals written in the English language, research based literature, non

peer reviewed articles, non research studies and grey literature relating to this topic.

Key terms used to search the databases were 'nurses' grief' 'patient death and staff',

'psychosocial factors and patient death', 'staff grief', 'emotional support and staff and

death' and 'social support and health personnel'. This resulted in a total of 73

articles from CINAHL, 62 from Medline and 34 from PsychInfo. Articles were

rejected for a variety of reasons. Some were concerned with grief issues for patients

and family members, not healthcare staff and others were not research but

subjective accounts of nurses' experiences of grief.

Following a comprehensive review of the literature, 17 studies complied with the

inclusion criteria for this review.

Following a thematic analysis of the literature, five themes consistently emerged.

These themes were the theoretical context, the emotional impact on staff, the culture

3
of the work environment, personal life experiences of staff and coping strategies.

These themes are discussed below.

Theoretical Context

Throughout the last century there has been a steady increase in the amount of

research concerned with loss and grieving. This has included the psychological,

biological and sociological aspects of loss and has covered a range of issues such

as physical, cognitive, behavioural and spiritual aspects of grief. Theorists who have

produced work on this topic are Freud (1949) who wrote about melancholia following

the death of someone close; Bowlby, (1980) who identified attachment theory and

discussed the notion of separation anxiety when a person dies and Lindemann (1944)

who produced work on the importance of rituals surrounding death and of group

mourning. These theories could be applicable to staff caring for patients, particularly

nursing staff who are likely to form attachments to those they care for and are often

excluded from any involvement in the rituals surrounding death and formal farewells

as in funerals and memorial events.

Kubler-Ross (1973) was the first to formulate the stages of grieving as a result of

her work talking to dying patients in a hospice setting. Others who have developed

models following their studies of grieving include Parkes (1975) and Worden (1991)

who identified tasks that the grieving person needs to work through in order to

successfully grieve. Stroebe & Schutt (1999) developed the Dual Process Model to

explain how grieving people alternate between behaviours that are related to

grieving and those related to adjustments in their lives to live without the person

whom has died. These theorists concentrated on how the bereaved express their

grief with the assumption that there is an acknowledgement of the loss to the
4
individual and their right to grieve is validated both by those around them and the

cultural norms of their society.

It was not until 1987 that Kenneth Doka developed the concept that some people

who are bereaved feel unable or are not allowed to express their grief. Doka (1987)

studied the impact of grief in non traditional relationships, that is for people

cohabiting or in- extramarital or homosexual relationships. The results showed that

whilst feelings of grief may be intense in these relationships, resources for resolving

grief may be limited. Informal and formal support systems may not be able to be

utilised as the relationship may have been secretive or unacknowledged by family

and friends and religion and rituals may constrain rather than assist the grieving

process. Doka called this concept disenfranchised grief, which he defined as a grief

experienced by an individual but which is not openly acknowledged, socially

validated or publicly observed (Doka, 2002) Healthcare staff may experience

disenfranchised grief in feeling it is not acceptable to express their emotional

response to a patient's death in the workplace environment. They may be called on

to support others in their loss with no acknowledgement that the death is a loss for

them as well.

Emotional impact of a patient death on healthcare staff

Rickerson et al (2005) conducted a quantitative study surveying 203 staff working in

six long term care institutions in the United States of America (USA). This research

found that staff experiencing the most grief related symptoms were those who had

worked longest in institutions and had closer and longer relationships with the

patients who died. The symptoms investigated in this research were physical,

emotional, relationships with family and co-workers and, effects on work

thinking about death and the negative impact the death had on their relationships

and performance both at home and at work. A limitation of this study was that as it

was restricted to set questions in a survey and it did not allow the staff to report other

effects they may have experienced but were not asked about. As it was conducted in

a long term care setting and in the USA these findings may not be generalisable to

an acute setting in the United Kingdom (UK), but may shed light on the possible

range of effects that can be present in staff.

Meaders and Lamson (2008) studied compassion fatigue in nursing staff in

paediatric intensive care units. Results of 185 completed questionnaires from

paediatric staff found that as children live longer with chronic conditions, nurses and

other care givers have increased and prolonged exposure to suffering and dying

children, which can lead to compassion fatigue. This is where staff lose the ability to

provide the same level of compassion to patients and their families as they have

previously (Figley, 2002). It is arguable that the same effect could happen with

nurses caring for adults with chronic conditions. As nurses care repeatedly for

patients with chronic illnesses it may be that they feel unable or unwilling to feel

compassion as the patients they care for suffer and die.

Elizabeth Kubler-Ross (1973) surveyed over 5,000 health care workers to discover

their experiences with death and also included how they worked with dying patients.

This study involved a range of health care workers including physicians, nurses,

social workers, psychologists and chaplains. The findings showed that 98% of the

respondents had difficulty with some dying patients. Trends were identified that were

associated with the different professions. Nurses identified that dealing with young

patients and those of their own age and gender was particularly difficult for them.
6
Psychologists and social workers reported pain as a difficult issue for them and they

identified this as being outside their area of expertise, knowledge and their

professional role. Although chaplains had usually worked with many people who

were sick, several expressed discomfort in actually talking about dying and felt

unable to answer certain questions patient's asked about their imminent death.

(Kubler-Ross, 1973).

Feldstein and Gemma (1995) studied whether nurses who left oncology wards to

work in other areas had a higher level of grief experiences than those who stayed in

this speciality. This was a quantitative study for which the researchers used a tool

called the Grief Experience inventory. The findings from 50 nurses who responded

showed both those who stayed and those who left this area of nursing experienced

social isolation, somatisation and despair as a result of caring for patients who died.

From the literature there is evidence that there is an emotional impact on nursing

staff who care for dying patients. Although this has been studied in a range of

settings no evidence was found of this topic being researched in acute adult wards.

The focus for most research studies seems to be the responses of healthcare staff

caring for children and babies or those working in palliative care settings. Much of

the research found is quantitative consisting of questionnaires and surveys. This

methodology does not allow the participants to relate their own individual

experiences but only to answer the questions set, many of which require a one word

answer. As seen from the statistics there are many more deaths that occur in adult

acute hospital settings; however the majority of the research concerning deaths in

this setting concentrates on supporting patients and their relatives and not on the

nurses themselves.

7
Impact of culture on the work environment

Culture is here defined as the patterns of behaviour, customs, beliefs and knowledge

of a group of people (Spradley, 1979).

Doka (2002) identified in his studies on non traditional relationships that the culture

where individuals live or work contains norms of behaviour that people adhere to in

relation to their response to death. These govern areas of behaviour, affect and

cognition. They also dictate what losses should be grieved over, how the grief is

expressed and who is eligible to grieve.

In accordance with these social norms those seen as being the most eligible to

grieve are family members of the person who has died. This may exclude friends,

colleagues and professionals such as healthcare workers who may have

relationships with the deceased but feel their grief is unacknowledged. Anderson and

Gaugler (2006) found this to be the case in their study of 136 nursing assistants

working in 12 nursing homes. Some staff perceived their grief to be disenfranchised

whereas others felt more able to openly express their emotions around death and as

a result reported less prolonged grief related symptoms.

The types of loss that can be disenfranchised according to Doka (2002) are divided

into three main categories each of which can be applied to healthcare staff.

The first is where the relationship between the bereaved and the deceased is not

recognised. Folta & Deck (1976) recognised that there was an underlying

assumption that closeness in relationships exists only amongst spouses and

immediate kin and that other relationships including care givers are often not

8
recognised. In the case of healthcare workers they may be viewed as having a

professional relationship with their patients and not an emotional one.

The second type of loss is where the loss itself is not recognised. Healthcare staff

may not acknowledge even to themselves that there is a loss in a patient dying. It

may be seen that it is part of the role of a nurse to care for patients who die, and

then to move on with their professional work without recognising that the death has

impacted them.

The third type of disenfranchised grief is where the griever is excluded, either

stopped from attending a funeral or engaging in grieving rituals or they may prevent

themselves from having any involvement. Health care staff may not be recognised

as having the status of a person who experiences grief or they may not permit

themselves to be involved in any grieving rituals.

Roper and Shapiro (2000) describe how cultures develop and are maintained in

medical and nursing settings which affect the behaviour and responses of healthcare

staff to certain situations in order to comply with what are seen as cultural norms.

They also write about how ward areas and units can develop and maintain a cultural

system. Hutchinson (1984) studied the cultural system of a neonatal unit exploring

the interactions of nursing staff to discover the patterns of behaviours and beliefs

held by staff in this area. This research concluded that perceived cultural norms can

have a strong influence on staff behaviours, attitudes and beliefs.

The impact of personal situations and life experiences

Nurses and other healthcare workers will have socio-cultural influences and personal

life experiences that they bring into their professional roles. The role of these factors

in influencing their response to death at work has been researched in a few settings.
9
Kubler Ross (1973) found that the difficulties identified by nurses when working with

dying patients were specifically of working with those of their own gender and age

and with young people. However as this research was conducted over 30 years ago

and in a hospice setting it may not be relevant to the current time and in an acute

setting.

Katz and Johnson (2006) claim that many nurses choose to work in end of life care

because of their own experiences of death, trauma and loss in their lives. Having

had a personal experience of the death of someone close to them is seen as

creating a personal-professional interface for the nurse between their own life events

and professional interactions (Genevay and Katz, 1990).

Papadatou et al (2001) compared the experiences of 63 nurses working with dying

children in Greece and Hong Kong and asked about their personal life experiences.

Ninety-seven percent of Greek nurses and 54% of Hong Kong nurses in this study

had experienced the death of a close relative. Most of the respondents reported that

these losses were well integrated into their lives, though a few acknowledged that

the experience of death in their personal lives remained unresolved. The

researchers found that nurses who reported difficulties in accepting the death of

someone in their personal life were more vulnerable when faced with the death of a

patient. This was particularly the case if the death of a patient had features which

reminded them of their own personal loss.

These studies do not indicate that personal experience of death has a definite effect

on the response to a patient dying, however research by Fisher (1991) found that

working with grief and bereavement in palliative care can put staff in touch with their

own losses and can heighten mutual empathy and identification.

10
Grief support and education for healthcare staff

Fessick (2007) reports that a staff retreat for 20 nursing staff from medical oncology

wards was found to be helpful in supporting staff through grief and helping them to

manage this aspect of their work. The retreat involved an education session on

theories of grieving and identifying coping strategies which could be used by staff.

Findings from interviews following the retreat showed that staff felt they had been

given key tools to improve their ability to cope, had been able to share their feelings

with others and an unplanned benefit was the development of a closer and stronger

team. These results indicate that creating a forum where staff can articulate their

feelings in a safe and supportive environment has benefits to individuals and the

group as a whole.

Research was conducted through qualitative narrative interviews with 14 nurses

working with pregnancy loss in gynaecology wards (McCreight 2004). This indicated

that education for staff in training or those qualified can help them to manage

feelings of grief and loss resulting from their work experiences. However they also

found that some staff did not want formal support or education as this could imply

they were unable to cope emotionally with their work. They would prefer relying more

on informal networks of talking to colleagues and friends both in and outside of the

work situation. This finding could suggest that there are strong cultural norms that

staff feel they have to adhere to.

Rickerson et al (2005) surveyed 203 staff in elderly care homes and found that over

80% of staff used informal support mechanisms such as talking to colleagues and

friends to help them cope with their response to a patient death and most said they

would use additional forms of support for example support groups and individual

counselling. As this research was carried out in the USA it may be that counselling
11
and support groups are more prevalent and acceptable there than in the UK. The

research by McCreight (2004) described above was conducted in Northern Ireland

and their findings do not support the provision of formal support groups.

Moores et al (2007) investigated the reactions of 188 doctors to memorable deaths

for them in three hospitals in northern England and their need for support. They

found that doctors who had received training on dealing with emotions showed

similar responses to those with no training. However no details were given of the

type of training received by the doctors so it is not possible to evaluate this finding.

Discussion

The studies reviewed acknowledge a range of responses to these experiences.

The death of a patient can have an impact on nurses both inside and outside their

work environment and can affect their relationships with others. Their personal

experiences of death outside work can contribute positively to their work situation if

these have been well integrated into their lives. However if personal experiences of

death are unresolved or there have been difficulties in accepting the death of a

relative or close friend then this can result in nursing staff being more vulnerable

when confronting the death of a patient. The culture of the work environment was

seen as a factor in determining how freely staff feel able to express their emotions

around patient death.

Compassion fatigue has been highlighted as a feature for some staff caring for

patients who are in pain, seriously ill and dying (Sabo, 2006). This has led to

research into what interventions could help staff to manage this condition. Aycock

and Boyle (2009) conducted a national survey of nurses who were members of the

oncology nursing society in the United States of America (USA) asking about
12
interventions available to manage this in their place of work. They concluded that

optimally organisations should provide pro active and preventative support services.

These could include counselling and educational input for nursing staff along with

retreat participation.

Education around grief theory and support from others were found to be helpful for

several staff in developing strategies for coping with patient deaths. This could be in

the form of formal teaching sessions or less formal staff meetings. It could involve

time away from the ward for staff to share their experiences and support each other.

Implications for practice

These findings could have implications for practice in terms of the provision of

continuing professional development for nursing staff. This review has indicated that

the education of staff around grief theory, support from others and the development

of coping strategies could help support nursing staff in this area of their work.

Awareness of their personal responses to loss and of the impact of the culture in

which they work may also contribute to their understanding and therefore their

responses following the death of a patient.

Conclusion

All the studies discussed above show that the deaths of patients do impact on the

nursing staff whom have been caring for them. Further research into some of the

areas mentioned above could provide useful information regarding how to support

nursing staff in these circumstances. This could include research into how

compassion fatigue can be diminished or prevented in differing hospital settings and

cultural environments.
13
The studies found in this review are from a small range of care areas and specialities.

Several are from oncology units, hospices and intensive care units which are

associated with a high incidence of patient deaths. Some of these areas have

support systems in place for staff. Other care areas covered by this review are less

acute settings including long term care facilities where patients can be present for

months or years. Further research is needed to guide practice in acute general

hospital wards and to identify the responses and needs of nursing staff in these

areas.

KEY POINTS

 The death of a patient can have an impact on nurses both in their work

environment and outside of work and can affect their relationships with others.

 From the literature, five themes consistently emerged. These themes were

the theoretical context, the emotional impact on staff, the culture of the work

environment, personal life experiences of staff and coping strategies.

 The findings form this review could have implications for practice in terms of

the provision of continuing professional development for nurses.

 Further research is needed to guide practice in acute general hospital wards

and to identify the responses and needs of nursing staff in these areas.

14
 References

Anderson K., Gaugler J. (2006) The Grief Experiences of Certified Nursing

Assistants; Personal Growth and Complicated Grief. Omega 54(4) p301-318

Bowlby J. (1980)Attachment and Loss Volume 3; loss sadness and depression

London, Hogarth Press

Costello J. (2001) Nursing older dying patients; findings from an ethnographic study

of death and dying in elderly care wards Journal of Advanced Nursing 35(1) 59-68

Doka K. (1987) Silent Sorrow; grief and the loss of significant others Death studies

11(6) p455-469

Doka K. (2002) Disenfranchised Grief New directions, challenges and strategies for

practice Illinois, Research Press

Feldstein M., Gemma P. (1995) Oncology Nurses and Chronic Compounded Grief

Cancer Nursing 18(3) p228-236

Fessick S. (2007) The use of a Staff Retreat with a Grief Counsellor for Inpatient

Medical Oncology Nurses to assist with Bereavement and Coping Oncology Nursing

Forum 34(2) p529

Figley C. (2002) Compassion Fatigue; Psychotherapists Chronic lack of Self Care

Psychotherapy in Practice 58 p1433-1441

Professional Nurse December 1991, p178-182

Folta J., Deck G. (1976) Grief, the Funeral and the Friend. In V. Pine et al (Eds)

Acute Grief and the Funeral Illinois, Charles C Thomas

Freud S. (1949) Mourning and Melancholia. In E Jones (Ed) Sigmond Freud MD

LLD Collected papers (Vol 4) London Hogarth press (original work published 1917)

Genevay B., Katz R. (1990) Countertransference and Older Clients. Newbury Park,

California. Sage Publications

Goodenough W. (1964) Cultural Anthropology in D. Hymes (Ed) Language in Culture

and Society New York, Harper and Row

Hutchinson S. (1984) Creating meaning out of horror: how ICU nurses survive and

work productively in a stressful environment. Nursing Outlook 32 p86-90

Katz R., Johnson T. (2006) When professionals Weep; emotional and

countertransference responses in end of life care New York Routledge

Kubler Ross E. (1973) On Death and Dying London Routledge

Lindeman E. (1944) Symptomatology and recovery from acute grief American

Journal of Psychiatry 101 p141-148

experiences in gynae wards International journal of nursing studies 42 p439-448

Meadors P., Lamson A. (2008) Compassion fatigue and secondary traumatisation;

provider self care on intensive care units for children Journal of Paediatric

Healthcare 22(1) p24-34

Moores et al (2007) Memorable patient deaths; reactions of hospital doctors and

their need for support Medical Education 41 942-946

Neimeyer R. (2001) Meaning, reconstruction and experience of loss American

Psychological Association

Office for National Statistics (2009) Mortality Statistics; Deaths registered in 2007

[online] www.statistics.gov.uk [last accessed 22 September 2010]

Papadatou D et al (2001) Caring for Dying Children; a comparative study of nurses'

experiences in Greece and Hong Kong Cancer Nursing 24(5) 402-412

Parkes C. (1975) Bereavement; Studies of Grief in Adult Life London Penguin

Parkes C (1998) Facing Loss British Medical Journal 316(7143) 1521-1524

17
Rashotte J. et al (1997) Pediatric intensive care nurses and their grief experiences; a

phenomenological study Heart and Lung 26(5) 372-386

Rickerson E. et al (2005) how well are we caring for caregivers? Prevalence of grief

related symptoms and need for bereavement support among long term care staff

Journal of pain and symptom management 30(3) 227-233

Roper J., Shapira J. (2000) Ethnography in Nursing Research Thousand Oaks,

California Sage Publications

Spradley J (1979) The ethnographic Interview Orlando, Harcourt College Publishers

Stroebe M., Schutt H. (1999) The dual process model of coping with bereavement:

rationale and description. Death Studies 23(3) p197-224

Walters T. (1996) A new model of grief: bereavement and biography Mortality 1(1)

p7-25

Worden W. (1991) Grief Counselling and Grief Therapy (2nd edition) New York,

Springer

18