Those in the discipline of nursing spend more time with dying patients than any other profession and this is particularly true in the field of critical care where mortality rates are the highest (Bloomer & O'Connor, 2012). In one study, thirty-seven percent of graduate nurses described feelings of discomfort when caring for patients who are dying (Casey, Fink, Krugman & Probst, 2004). Research has demonstrated that newly licensed nurses have reported feelings of being scared and stressed; others have mistakenly believed their fear and guilt somehow contributed to a child's death (Vanderspank-Wright, Fothergill-Bourbonnais, Malone-Tucker, Silvar, 2011). Current research supports the need for additional coping strategies for pediatric nurses such as colleague support and institutional resources when caring for a child who is dying (Cook, et. al., 2012). Job disatisfaction with new graduate nurses has been examined and as many as 17.5% of new nurses will leave their first job within one year (Kovner, Brewer, Fatehhi & Jun, 2014). Nurse turnover continues to be an international concern and has been studied throughout the world (Chen, Chu, Wang, & Lin, 2008; Josephson, Lindberg, Voss, Alfredsson, & Vingard, 2008; Camerino, et al., 2008; Morrell, 2005; O'Brien-Pallas, et al., 2006).
Methods: A qualitative study design was selected to best inform the identified gap in the literature and to describe death and dying from the perspective of the newly licensed nurse in the PICU. An expedited IRB approval was obtained from a free standing quaternary care children’s hospital in the northeastern United States. Newly licensed nurses were asked to privately share their experiences with death and dying in the PICU. Inclusion criteria was less than 3 years of experience as a nurse, employed in a PICU, and one who had cared for a child who was dying or had died. Thirty-five nurses met inclusion criteria and received an email invitation to participate in an audio-recorded 45-60 minute 1:1 interview about their experience. The interviewer was the instrument and the interview was the tool. The interviewer was a hospital based nurse scientist with expertise in qualitative research methodologies who had no supervisory or evaluative responsibility. Participants were not identified, and interviews were transcribed verbatim with all identifiers removed. All data was reported in aggregate. The data analysis followed Colaizzi’s 7-step method (1979) to assure credibility, trustworthiness, reliability and potential replication.
Results: Expressive and poignant perspectives of the nurses were gained through in-depth interviews. The participants reflected on the first experiences of caring for a child who died. The participants were the experts and were asked to share their thoughts and remembrances which led to rich data. During data immersion, multiple impressive statements were extracted and contributed to the emergence of two central themes which were The Journey and Recommendations. The subthemes that supported the theme The Journey were Doesn’t Seem Real until You’re There, Technology: A Blessing or a Curse, Response to Death, Timing of Death, Empathic Presence and Tasking Care of Self. The subthemes that grew out of Recommendations were Support and Additional Education.
There still remains a paucity of research specific to newly licensed nurses’ experiences with death and dying in the PICU. The participants reflected on what had become their journey upon the sea of life and death. Life they understood and felt confident about with their skill set. Death however, was filled with dread and uncertainty. Experiences prior to employment were few and exposure and information to their role was minimal. They all agreed that the experience was one that doesn’t seem real until you’re there. Participants discussed technology as both a blessing and a curse and were not sure which was more significant and at times which was preferred. The timing of death influenced how they responded to the death. They were challenged about how to respond to various kinds of deaths, while simultaneously juggling the need to provide empathic presence to family members at all times. Taking care of self then emerged as an important realization after participating in many encounters of such overwhelming experiences. Ultimately, recommendations that included more support and additional education were provided by participants in an effort to make it better for themselves and the next generation of newly licensed PICU nurses.
Nursing practice is dynamic and does not hold one worldview for all. Our results helped us to understand what newly licensed nurses perceived to be helpful during the death and dying process in the PICU. To date, the nursing research literature has not addressed this unique topic. It is hoped that a better understanding of this phenomenon will guide curriculum changes at the undergraduate level as well as provide information for the new graduate staff nurse orientation class. Limitations include the sample which was small and purposive which may not be transferable to all newly licensed nurses outside of one institution and specialty.
Conclusion: This qualitative research study served to enlighten our understanding of the experiences of the newly licensed nurses with death and dying in the PICU. The final results from this study are critical as many newly licensed nurses now seek to start their career in the PICU setting. In addition, many newly licensed nurses are being given preference in employment as they are less expensive for an institution to hire than an experienced nurse. This research will help academic and clinical educators to understand the newly licensed nurses’ experiences with end-of-life in the PICU. It may also transform how the discipline teaches and prepares nurses to work in this environment. Future implications for practice may include additional teaching, support and self-care for the newly licensed nurse. It has been stated that the ability to provide high quality end-of life care for the child and the family is the most intimate act of nursing care (Ronaldson, 2006). This research identifies the need for PICU nurses to be better prepared to provide high quality end-of-life care for the dying child while also honoring and supporting the family. The findings of this research study are just the beginning of a body of knowledge that aims to address the ongoing needs of the newly licensed nurses employed in pediatric critical care.
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