Edinburgh Napier University

  Background
The population in Scotland is ageing with a projected increase of 75% in the over 75’s by 2031. Currently over 55,000 people die in Scotland each year. This figure however is increasing and over half a million people will receive end of life care and die in acute settings in the next twenty years. The palliative and end of life care (PEOLC) needs of the population will increase and will be delivered more frequently in acute settings. The personal experiences of the nurses delivering PEOLC in a busy acute environment therefore require to be reflected upon, understood and acknowledged. Nurses experience grief for their patients, but do so in a very different manner to that experienced by the patient’s family. The nurse often finds them self in conflicting roles as they feel they need to remain strong and offer support on one hand whilst managing their own emotions and acknowledging their loss on the other. Managing their experience of professional grief following the death of a patient with whom they may have formed a connection can be very difficult. This purpose of this study is to understand the experiences of palliative care nurses delivering PEOLC in an acute settings and how they make meaning following loss and death of patients.

Methods
This research was underpinned by a reflective approach and engagement with the participants using an Interpretive Phenomenological Analysis (IPA) methodology. IPA has become a credible methodology for studying consciousness generally and in nursing in particular. Analysis of the meanings being lived by participants from a psychological perspective can be illuminating and revealing in nature. Seven nurses were recruited using purposive sampling from a palliative care ward based in an acute hospital setting. The researcher was able to cultivate a deep level of trust and collaboration through having knowledge and experience of the palliative care nursing role within an acute hospital setting and an understanding of the roles and responsibilities within the team. Data were collected through seven semi structured interviews which were audio recorded then transcribed, field notes were recorded prior to the interviews and reflections were audio recorded post interview. The three data sets were drawn together to triangulate findings. The analysis which ensued combined the researcher and participants reflections, double hermeneutic approach.

Findings
Following analysis of the findings, four main or superordinate themes were revealed. These were the importance of being, the altruistic self, separating the personal and the professional self and death anxiety and transference. The nurses instinctively knew when being with the dying patient was not only needed but also invited. The nurses inherent values and altruistic tenets ensured they delivered care to the highest standard they could, and believed that this contributed towards a good death for the patient. They felt personally responsible for ensuring a good death was achieved. The nurses did experience a form of professional grief and feelings of loss for their patients following their death. The process of experiencing grief, although often short lived, caused concern to the nurses. They perceived it as not being professional to show outward signs of grief as their primary role was to support the dying and bereaved. Death anxiety and transference were consequences of delivering palliative and end of life care in this setting. Although nurses sought to address these experiences through processes of reflection and team support activities, evidence of distress and grief persisted.

Conclusion
Nurses are sentient thinking beings whose lived experiences and feelings affect their thoughts and emotions. This in turn impacts not only on their personal life but also their professional identity and perceptions of good quality care. The caring processes they enact shapes and informs their understanding of the world and their experiences therein. The findings of this study point towards a need to understand and acknowledge that nurses can experience professional grief for their patients and it is necessary therefore to consider effective supportive mechanisms such as reflection and formal clinical supervision for nurses delivering PEOLC in acute settings. This could support wellbeing, where nurses care for themselves and each other whilst delivering end of life care. Following identification of the findings an illustration depicting a visual representation of the process of professional grief experienced by nurses delivering PEOLC in acute settings is presented. Four stages of being were identified within the process. These were feeling prepared, experiencing loss, making meaning and finally letting go and moving on. The conclusions and illustration depicting a visual representation of the process of professional grief have been grounded in the findings from this study and therefore offers an original contribution to the knowledge and understanding of the experiences of palliative care nurses delivering PEOLC in acute settings.