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«Abstract Background: There were 509,090 deaths recorded in England and Wales for 2008 (ONS, 2010). Of these numbers over 56% (260,000) occurred in ...»

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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).


The aim of this literature review is to explore how the death of patients in a hospital setting impact on nursing staff.


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.


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.


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.

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.

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 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 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 performance. The most common reported effects were feeling sad, crying and 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.

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.

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 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.

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