Phenomenon of sudden death: Part 2

Phenomenon of sudden death: Part 2 J. C. Saines This study investigates qualified nurses’ experiences of the phenomenon of sudden death within the Accident and Emergency speciality. The author’s objective was to deepen knowledge and understand the phenomenon from the perspective of nursing colleagues. The sample size was six participants drawn from the Accident and Emergency department of a large hospital in the South East of England, UK. A phenomenological approach was used: data collection being by unstructured interviews and analysis by using Hycner’s (1985) approach. Four chronological themes were identified which form a structure to the nurses’ experiences: encountering, facing, dealing with and reflecting upon the phenomenon of sudden death. The results emphasize the value of reflective practice linked to effective and relevant training within a safe and supportive work environment. The research findings fully acknowledge the difficulty of coping with what can be one of the most stressful aspects of an Accident and Emergency nurse’s role. Using phenomenology to understand the lived experience enhances the knowledge needed to minimize nurses’ stress and increase their job satisfaction. The insights gained can significantly contribute to the provision of high quality holistic care for the suddenly bereaved. Part 1 (published in issue 5:3) covered sudden bereavement from the A & E nurse’s point of view, the research design and methodology, and the research findings Part 2 presents the discussion of the findings, as follows. Janet C. Saines BSc (Hans), RGN S~sier Accident and Emergency, Wycombe General Hospital, Queen Alexandra Road, High Wycombe, Bucks HP I I 2iT; UK Manuicr~pt accepted I997

I2 May

DISCUSSION

OF THE

FINDINGS

This small-scale study offers a view of the lived experience of sudden death from practising qualified Accident and Emergency (A & E)

Acc~dentandEmergencyNurs~ng(1997)5.205-209OHarcourtBraceand

Company

Lrd 1997

nurses. The author wishes to acknowledge the contribution of the study participants. The process of analysis was, for the author, emotionally moving as realization dawned as to the amount of mutual trust, shown by the depth and colour of the interviewees’ narrated experiences. Schutz (1994) asserts that to generate experiential knowledge requires a relationship between researcher and informant which is built on trust. In addition, Allen & Jensen (1990) contend that there is an ‘emotional relationship’ with the text which necessitates the researcher bringing to the work their own experiences, values and personal perspective. By using the phenomenological approach, this study acknowledges that individual nurses will have unique experiences of sudden death. However, similar factors contributing to that experience recurred time and time again during the interviews. These similarities were grouped into the four chronological themes of encountering, facing, dealing with and then reflecting upon each occurrence of a sudden death situation in A & E. The themes interlink to form a four-stage cyclic process which provides a unique view of, and a structure to the phenomenon from a nursing perspective.

Encountering For nurses in their professional life, as Bond & Bond (1994) indicate, personal encounters with death cannot be avoided in the same way as many people in society do. Furthermore, these encounters are complicated by the unpredictable and diverse nature of A & E work (Robinson & O’Connell 1995). However, as Saunders & Valente (1994) emphasize, while the common occupational hazard of patient deaths may evoke intense negative reactions they can inspire intense positive responses that promote professional development. Study participants highlighted the unexpected and unpredictable nature of their experiences when confronted by the suddenness of the encounter. McCord (1990) accentuates ‘the abrupt transition from life to death’ which ‘shocks professionals’. Nurses also experience a high level of difficulty coming to terms with their encounters, particularly when young people are involved. The impact on nurses of the sudden, unexpected death of a previously well child is often beyond measurement (Greenberg et al 1993). Additionally Saunders & Valente (1994) suggest that encounters with death leave a lasting impression even though the incidents may not be consciously remembered. This observation reminded the author of a conversation following a study interview, when a participant remarked, ‘I can’t believe it! I didn’t realize that I could remember all that. It just came out.’

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Facing Hospice nurses’ perception of the ‘good death’ has been explored by McNamara et al (1995). They define the concept, as having nurse involvement, and where the patient is able to complete their living, dying pain-free, peacefully and with dignity. The author’s findings obviously demonstrate that sudden death in A & E often fails to meet any of the criteria. A & E nurses rarely have the opportunity to positively influence the quality of their patients’ deaths. This aspect makes a significant contribution to the nursing distress when facing death in the department. The physical horror of sudden death was graphically described by the nurses in the study, The vivid intensity of these descriptions could be due to the author’s dual role as a researcher/nurse. Participants acknowledged that there are elements of their work which they would not freely discuss outside their profession. Data findings emphasize the emotional turbulence of facing sudden death. Study nurses expressed emotional empathy as they realized the effect of death on the lives of the suddenly bereaved. Adamowski et al (1993) suggest few emergency department personnel are prepared for the ‘emotional turmoil’ that can accompany sudden death. Consensus was found amongst study participants as to the emotional difficulty in coping with the rapid transition that occurs at death, when the focus changes from medical control to nursing care and responsibility. The author’s findings endorse Solursh (1990) who observes that there are many doctors who would far sooner face problems with the trauma patient than deal with the bereaved family. Perhaps the reason is, as Holman (1990) suggests, the pervasive attitude that ‘death represents failure of medical expertise’. Worden (1991) suggests that facing death can touch our personal lives in three ways: to awaken previous loss; to heighten the awareness of feared losses; and to challenge our own mortality. The findings from the study reflect all three aspects. Speck (1994) summarizes: We are repeatedly put in touch with past losses and reminded of the certainty of future ones. Each time, we are confronted with the reality that our work does not confer any

special protection against death.

Dealing

with

Without the benefit of establishing prior rapport with the family (Walters & Tupin 1991), A & E nurses need to anticipate and meet the needs of the suddenly bereaved in order to facilitate the grieving process (Tye 1993). Overall, the study findings reveal the difficulty in dealing with this group because of the necessity to carry

out a rapid and sensitive assessment of their needs without previous knowledge of the family dynamics. The challenge of empowering them back into reality against the intense weight of their emotional crisis can represent the ultimate test of the nurse’s professionalism. The experience of supporting the relatives through the procedure of witnessed resuscitation produced ambivalent reactions from the study nurses. These findings support the mass of literature that is available on this topic (Wright 1996). Chalk (1995) emphasizes that each situation is different and attendance cannot be an option for every family, However, Gregory (1995) passionately advocates that how grieving relatives deal with the experience is up to them, and not the professionals. Bates et al (1993) define the psychosocial skills needed for professional competence when caring for the suddenly bereaved. They cover the areas of emotional, intellectual, spiritual, interpersonal, social, cultural and economic dimensions of the human experience. Study nurses talked about their feelings of inadequacy in meeting with these challenges, confirming the workshop findings of Wright (1996). March (1995) suggests that the central difficulty in caring for the bereaved appears to be the strong sense that it imparts in carers of being quite unable to help. But as Wright (1989) reminds nurses, if you feel ineffective or impotent, do not be afraid to fall back on your own personal skills, your own humanity. The grief reactions of relatives in sudden death situations are individual, intense, diverse and wide-ranging. Many of these grief reactions were identified in the experiences of the study participants. McQuay (1995) states relatives may be immobolized in a shock-like state, rendered vulnerable and helpless when faced with the sudden loss of a loved one. The data findings reveal a strong protective instinct as nurses promote the rights of the bereaved. Saunders & Valente (1994) highlight the frustration felt by nurses when their advocacy is challenged by other professionals. The challenge to professional composure is ever present in the A & E department when caring for the suddenly bereaved. All the study participants vividly expressed their difficulties in coping with the personal responsibility of emotional labour. Hockey (1993) eloquently describes the assault of inner forces which despite a belief in the therapeutic value of emotional expression, can be seen to represent a threat to professional competence. Loss of emotional control in a professional and public setting can be problematic, in that control, once lost, cannot easily be retrieved. However, Dyer (1993) suggests that the key is compassion - if you care and show that you care, then you will almost certainly support the bereaved appropriately.

Phenomenon

Senior nurses in the study focused attention on their experiences when managing the A & E department. Wells (1993) succinctly points out that A & E is primarily an area where lives are saved, not lost. This ‘vital function cannot be thwarted’ even in the presence of grieving family members. Furthermore, senior staff highlighted the need to carefully monitor junior staff in sudden death situations. March (1995) advises it is the responsibility of ‘the employer’ to ensure that nurses are not damaged by their work. Findings from the data reveal a dedicated desire to help the bereaved to regain a measure of control over their lives. In such an emotional atmosphere, study nurses therefore found themselves in conflict with management, colleagues and other health professionals. Saunders & Valente (1994) suggest value conflicts may emerge when a death appears unnecessarily difficult, when patients’ wishes are overlooked and when staff disagree on care. In summary, study participants spoke freely of the difficulties in dealing with the suddenly bereaved. The findings illustrate a high level of commitment to relatives as they struggle to reclaim their emotional equilibrium in the face of their loss. Study nurses recall the factors intrinsic to A & E which hinder the provision of quality care. The suddenness of the event coupled with the inability to establish prior rapport gives A & E nurses no time for preparation to handle the wide range of issues associated with sudden death. The high-tech, physically-orientated, medically-dominated, life-saving culture of A & E together with its unpredictable workload provides a singularly inappropriate environment in which to provide emotional care.

Reflecting

upon

Study participants revealed a high level of perceptive analysis when reflecting upon their experiences in encountering, facing and dealing with the phenomenon of sudden death. Ganner (1996) states that reflection is an aptitude which can be used and refined by nurses to underpin their practice. Reflection is the process, asserts Laight (1995), of ‘creating and clarifying the meaning of an experience for oneself.’ Additionally Bulman (1994) suggests that while reflection can be painful, it could be that such an outlet for exploration of emotions is cathartic for the practitioner. The findings from the data demonstrate use of all three functions. Study nurses acknowledge the intensity of emotions that sudden death can provoke within them. They graphically expressed the need to release these emotions through an abreaction process. Speck (1994) proposes that nurses ‘need

of sudden

death:

Part 2 207

space to understand what they are carrying psychologically as a result of the work they do’. Furthermore, according to Fieldstein & Gemma (1995), nurses need to know that these feelings are normal and there are ways to deal with them. A significant finding from the data was the time element needed for emotional recovery before nurses are able to encounter another sudden death situation. Failure to restore emotional equilibrium can lead to severe distress and even burnout for the nurse. This consequence is highlighted by Saunders & Valente (1994) who assert that ‘overload’ occurs after significant or multiple deaths, when nurses lack time to reflect upon or settle their own responses. Support for the nurse is an essential component in coping with the emotional aftermath of a sudden death situation. Study findings demonstrate the varied nature of such support and the discrete requirements for the individual. March (1995) declares that all nurses who are working in an area in which death occurs regularly should have access to a support system. Bolton & Roberts (1994) stress that support is needed to enable staff to ‘face’ rather than evade ‘difficult issues’. Debriefing after the crises also reduces the worker’s anxiety level, and provides an opportunity to learn from the experience (Hoffenberg 81 Buck 1994). Every nurse in the study emphasized the importance of a satisfying and meaningful conclusion to their involvement in each sudden death episode. They recognized the mutual benefits that can be obtained by achieving such a conclusion. These findings corroborate Anderson et al’s (1991) proposition that the use follow-up programme of a bereavement encourages a healthy completion of the grievfamilies and job ing process for patients’ satisfaction for the nursing staff. The same conclusions were drawn from an A & E study carried out by Ewins & Bryant (1992). Study nurses accredited the significance of experiential knowledge in improving their professional practice in sudden death situations. This process can be augmented by the provision of related and pertinent training. Tye (1993) comments that in the absence of trainmany A & E nurses ‘learn’ ing programmes, through repeated exposure to sudden death events. Thus bad skills can become entrenched and difficult to unlearn. In summary, when reflecting upon the totality of their experiences with the phenomenon of sudden death, the study nurses identified three objectives: emotional expression; a meaningful conclusion; and how to build a sound knowledge base. In order to achieve their aims, nurses recognized the importance of reflection allied to relevant training in a strongly supportive environment.

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B

IMPLICATIONS

FOR PRACTICE

The themes generated by the phonomenological study build a four-stage cyclic process to create a structure for the experience of sudden death. This logical structure not only formulates an understanding of the phenomenon from a nursing perspective but also provides a framework in which to evaluate the implications for practice of the study’s findings. The nurses’ experiences under the theme of reflecting upon revealed the value of reflection linked to relevant training cerebrated in a safe supportive environment. The main implication for practice is the necessity to provide and maintain a ‘culture of caring’ within A & E departments, where nurses are encouraged to develop their professional practice in an open and non-threatening atmosphere. Palmer (1994) comments that the drive for efficiency and cost effectiveness within health services often leaves little time for an individual nurse or group of nurses to reflect on their clinical practice. However, Poole (1995) states that reflection is an ‘essential component of self-evaluation’ which is crucial to both personal and professional development. A formal follow-up support system for the suddenly bereaved will not only provide a needed conclusion to each sudden death occurrence for nurses but will also produce a structured impetus to the process of reflection. Findings from the study emphasize the requirement for staff to be allowed to express the emotions f?om each occurrence before encountering another; endorsing a recommendation made by the British Association of A & E Medicine & RCN (1995). McNamara et al (1995) affirm that nurses actively negotiate their own support systems from within and outside the hospital environment. However, Dimond (1995) points out that the employer has a duty to support A & E staff who may be considerably stressed by the traumas of their work. A & E departments, therefore, should provide opportunities for formal or informal de-briefing sessions after difficult sudden death incidents. Consideration should be given to the formation of a staff support group to encourage open discussion of those personal feelings which are connected with the workrole (Bolton & Roberts 1994). The establishment of the ‘culture of caring’ will help to foster and nurture nurses’ informal support systems with their colleagues. Effective death education will assist nurses through the stages of encountering and facing the phenomenon of sudden death in A & E. Durlak & Riesenburg (1991) assert that one of the main purposes of death education is to help individuals face and cope with death more

effectively. To improve self-awareness and interpersonal skills, Slater (1988) and Wright (1996) advocate workshops where health carers review previous bereavement situations to gain from the process of self-exploration and shared learning. The author’s recent experience of developing tailored work-group training in this area for A & E colleagues strongly endorses this view. The education not only enhanced the ‘culture of caring’ but also evoked a deep sense of bonding within the department. When dealing with the suddenly bereaved, the study emphasized the difficulty for A & E nurses who, without any prior relationship, are confronted with relatives in shock induced by the acute crisis of their sudden loss. To help nurses through this sensitive and immense task Adamowski et al (1993) recommend a consistent intervention strategy supported by relevant training to ease anxiety and to provide an understanding of the needs and expectations of the suddenly bereaved. The A & E department needs to provide a multilaterally defined protocol; a particular set of activities which assists healthcare workers to respond consistently in complex areas of clinical practice (RCN 1993). Training in the many and varied issues surrounding the care of the relatives should be augmented by the provision of a reference library within the department. The words of Sbaih (1995) provide a succinct conclusion, Individual and team commitment to professional and personal development should be encouraged via the recognition of experience, education and maintenance of competence. Quality holistic care for the suddenly bereaved can only be successfully given in an A & E department permeated with a ‘culture of caring’. The author acknowledges that the scale of the study limits the extent to which the findings can be generalized. However, because of its setting, the author feels that the findings and recommendations will have general applicability in the A & E speciality. Additionally, because death is universal in the hospital environment, understanding of the phenomenon generated by the four stage cyclic process and its associated themes could well be transferable to other nursing specialities. REFERENCES Adamowski K et al 1993 Sudden unexpected death in the emergency department: caring for the survivors. Canadian Medical Association Journal 149(10): Allen MN, Jensen L 1990 Hermeneutical inquiry: meaning and scope. Western Journal of Nursing Research 12: 241-253

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