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Suddenly Feeling Dark A Qualitative Study On.3
Suddenly Feeling Dark A Qualitative Study On.3
3, JUNE 2023
DOI: https://doi.org/10.1097/jnr.0000000000000554
•
Maria Yoanita BINA
1
The Journal of Nursing Research Petrus Kanisius SIGA TAGE et al.
long and persistent grief as a psychiatric problem that can in- had lost a coworker in the same workspace, had known that co-
crease the risk of various stress-related disorders, heart problems, worker for more than 3 years, had worked in the COVID-19 iso-
addiction behaviors, immune system dysfunction, impaired qual- lation ward, were willing to share their experiences, and scored
ity of life, and suicidal ideation. COVID-19-related deaths repre- > 25 on the Inventory of Complicated Grief (ICG). An ICG score
sent a “perfect storm” triggering prolonged loss-related sadness. greater than 25 correlates with the presence of significant impair-
Nurses in the process of grieving have expressed increases in ments in social, general, mental, and physical health functioning
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emotional, moral, and secondary traumatic stresses at work and loss-associated bodily pain (Prigerson et al., 1995). Individ-
(Omran & Browning Callis, 2021). A concept analysis has uals with multiple bereavement problems are generally the most
defined the process of grieving in nurses as feelings aimed informed individuals. Exclusion criteria included nurses who
at the healthy resolution of loss and grief accepted through de- had communication problems during the interview, nurses
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nial, anger, disorganization, reorganization, and depression who refused to be interviewed because of emotional instability,
(Brunelli, 2005). and nurses infected with COVID-19. A demographic datasheet
For many nurses, coworkers are a “second family” with was used to collect information on gender, marital status, years
which they may share their important moments, solve prob- of service, religion, and culture.
lems, and celebrate successes (Laskowski-Jones, 2019). Studies In this study, 12 nurses were excluded from the interview
show that coworkers can provide support to improve the qual- process because of communication problems during the in-
ity of care, the handling of stressful situations in nursing, and terview process, being infected with COVID-19, and not
job satisfaction (Khatatbeh et al., 2021). Yin and Zeng (2020) meeting the specified inclusion criteria. Data saturation was
explained that coworkers helped satisfy the psychological need reached with the 23rd participant. The first eight participants
of nurses for interpersonal relationships during the pandemic. were recruited using purposive sampling to increase maxi-
Nurses grieving the loss of a coworker during the COVID-19 mum variation, with the remaining 34 participants recruited
pandemic experience significantly increased psychological by snowball sampling. The recruitment process for partici-
stress because of their concurrently high workload and gru- pants was performed in each province via a national nurse
eling shift schedule burdens (M. M. Zhang et al., 2021). In- organization network, and initial contacts were made with
creased psychological pressures accelerate burnout and turn- participants through care unit managers.
over in nurses (Mirzaei et al., 2021) and exacerbate the already
severe nursing shortage (Turale & Nantsupawat, 2021). De-
spite the many reports of nurses dying from COVID-19, few Data Collection
studies in the literature have addressed the impact of these In this study, interviews were conducted via the online Zoom
deaths on nursing coworkers, resulting in a lack of information remote conferencing application using a semistructured ap-
necessary to develop counseling and psychological support proach between December 2020 and August 2021. Four of
strategies for nurses who are continuing to handle the massive the researchers had received formal training in qualitative re-
wave of COVID-19 cases. search. Two of the authors served as interviewers and ex-
plained to each participant the purpose of the study and rel-
Aim evant details such as the interview method used and the need
This study was designed to elucidate the experiences of nurses for voice recordings. All of the collected information was
in Indonesia facing the loss of a colleague who died during the kept confidential. Before the interview, the researcher con-
COVID-19 pandemic. ducted an ICG questionnaire with the participant to identify
their level of sadness. Each interview lasted 90 minutes and
was conducted in Indonesian. Each participant participated
in the interview process twice to ensure the truthfulness of
Methods the information provided. The interview guide included ques-
tions addressing the following: (a) feelings and experiences af-
Study Design ter losing a coworker, (b) opinions regarding support needed,
A phenomenological study design was used to explore the (c) coping strategies used to deal with the grieving process,
concept/phenomenon underlying the awareness of participants and (d) future expectations. The researcher adjusted the phras-
regarding the loss of a colleague during the COVID-19 pan- ing and sequence of questions based on the circumstances in
demic. Phenomenological studies are conducted in realistic sit- each interview session. The researcher made every effort to
uations to minimize the limits to interpreting or understanding maximize dialogue and maintain an empathic understanding
the phenomenon under study, allowing researchers to freely an- of the participants' symptoms and feelings. During the inter-
alyze the data obtained (Wojnar & Swanson, 2007). view, observational notes on participants' affective responses
(e.g., laughter, tears, sadness, impatience) and sensitive words
Participants and Setting were recorded to provide contextual information for subse-
The participants were 42 nurses spread across four provinces quent analysis work. After being interviewed, all of the partici-
in Indonesia, including DKI Jakarta, Bali, East Java, and East pants were provided psychological counseling by the third au-
Nusa Tenggara. The inclusion criteria included nurses who thor (who is a certified professional counselor).
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Nurses Facing the Death of a Coworker VOL. 31, NO. 3, June 2023
corded content once after the interview session to understand 0049/2021). Permission from the hospital director was received
the participants' statements. Next, two researchers copied before data collection. All of the prospective participants were
and translated the interview data into English and then pro- given a research information sheet regarding the purpose of the
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vided comments. Each data item useful in answering the re- study, the role of the researcher, data confidentiality protocols,
search question was then coded. the right to withdraw, and the length of the interview. Written
Subsequently, coded data were analyzed, with different consent was obtained from each participant before interviews
codes combined according to an ordinary meaning to form were conducted. Permission was obtained directly from the
themes and subthemes. Two of the researchers reviewed the nurses involved in the study.
relationships between the data items and codes that informed
each theme and subtheme to form a coherent, logical pattern
and contributed to the overall narrative of the data. Two other Result
researchers assessed how well the themes interpreted the data Thirty participants who had lost their coworkers volunteered
in terms of the research question. After the candidate themes to participate in this research interview. Data saturation was
were determined, the themes were named based on a detailed reached at the 23rd participant. The 23 participants consisted
analysis of the thematic framework. Each theme provides a of 12 men and 11 women. Most were from Jakarta and East
coherent and internally consistent data report that does not Java, with eight participants each. The average age of the par-
overlap with the other themes. The four authors established ticipants was 37–41 years, 11 were married, ICG scores
the themes reported in the final data analysis phase. The ranged between 25 and 36, most held a 3-year diploma as
themes were connected logically and meaningfully to build their highest level of education, and 11 of the participants
a convincing data narrative. were Muslim. The themes identified in this study, which de-
scribe the stages of dealing with grief because of the loss of a
coworker, are shown in Table 1.
Trustworthiness
Trustworthiness in this study was ensured following the steps Theme 1: Responses in the First Stage
of Denzin and Lincoln (2017), including credibility, transfer-
ability, dependability, and confirmability. Credibility was Shocked to hear of colleague's death
achieved by conducting two interviews with the participants Shock and rejection were common reactions of participants to
to explore their experiences in detail and by engaging for hearing about the death of a coworker. Denial does not mean de-
extended periods with participants to ensure that partici- nying that a loss has occurred (although this may be the case) but
pants fit with the purpose of this study and that the data ob-
tained addressed the research objectives. Credibility was also
Table 1
achieved by allowing participants to share experiences with-
out providing other opinions and by recording participant Themes and Subthemes
expressions in field notes to facilitate the data coding process.
Theme Subtheme
The improvement of data transferability was achieved by using
sampling methods and qualitative research designs, using re- 1. Responses in the Shocked to hear of colleague's death
search problem background information from previously pub- first stage Self-blame for failing to save a life
lished research, clearly defining the demographic data charac- Afraid to experience the same
teristics of participants, and identifying 42 participants with situation
sufficient conditions for qualitative research. Thus, dependabil- 2. Responses in the Make efforts to avoid the same thing
ity was achieved, a clear and targeted detailed research protocol second stage from happening again
was drafted, and the four researchers rechecked the accuracy of Develop strategies to avoid thoughts
the data during the data analysis process. Confirmability was of loss
implemented by triangulating investigator data. This process Expect to have a psychological
support system
included engaging several researchers in the interview process;
keeping a diary related to research developments that deter- 3. Responses in the Seek new reasons, goals, directions,
mined the topics, methodologies, data analysis, results inter- third stage and meanings in life
Improve the physical and social
pretation, and conclusions; and conducting regular research
health of individuals
team meetings to discuss interpretations, codes, and themes.
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The Journal of Nursing Research Petrus Kanisius SIGA TAGE et al.
rather involves denying the experience of all feelings. In addition, COVID-19 patients, especially when dealing with death and
when nurses experienced the COVID-19-related loss of co- comforting bereaved family members. We must do it whole-
workers during the initial pandemic wave in March 2020 and heartedly. If we have a clear conscience, our sorrow is re-
May 2021, they were often unprepared because of the low level duced. (Nurse 1)
of awareness and psychological support received. They expressed Every time I go home, I reflect on my day's work. For exam-
regularly feeling nervous and confused, being sweaty, and ple, after some patients died from asphyxiation, I thought about
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experiencing an increased heart rate. Moreover, colleagues whether there were errors in the treatment procedure. (Nurse 22)
who died were immediately cared for by them.
When my companion died, I fainted, and my vision suddenly Develop strategies to avoid thoughts of loss
darkened. It went too fast, and I didn't expect it. (Nurse 23)
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Nurses Facing the Death of a Coworker VOL. 31, NO. 3, June 2023
to improve physical fitness or reduce illness, especially to the adverse effects of emotional problems. However, unhelpful
avoid problems with their coworkers. coping strategies can exacerbate emotional distress (Smith &
I bought some traditional medicine to drink to boost my Ehlers, 2023). Thus, nurses must learn to accept their loss
immunity (Nurse 8) and implement self-control. Schnell and Krampe (2020) found
I have hypertension. I have a blood pressure meter. I take that self-control can suppress one's emotions.
my blood pressure every day (Nurse 16) Nurses express a diversity of emotions in response to
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deal with the death of a coworker during the COVID-19 COVID-19 pandemic in China. All of the interviewees in that
pandemic. The emotional expressions in the first stage in- study stated that negative emotions could be effectively elimi-
cluded (a) being shocked to hear of colleague's death, (b) nated by shifting attention toward interests. They preferred to
blaming oneself for failing to save a life, and (c) being afraid focus on their work and chose to do leisure activities.
to experience the same situation. The actions in the second Nurses must adopt effective coping strategies that reflect
stage included (a) making efforts to avoid the same thing from the conditions experienced when dealing with emotional stress.
happening again, (b) developing strategies to avoid thoughts Because no coping strategy is definitively good or bad, coping
of loss, and (c) expecting to have a psychological support sys- will be effective only when it suits the individual character. Ap-
tem. The changes in the third stage included (a) seeking new propriate coping strategies can reduce or buffer the harmful ef-
reasons, goals, directions, and meanings in life and (b) im- fects of emotional problems (Liang et al., 2020).
proving the physical and social health of individuals. The course of the coping process necessarily reflects the
The participants showed strong emotional expressions af- personal resource and social support situation of each individual
ter the death of their coworkers. Studies show that death is a (Babicka-Wirkus et al., 2021). In this study, the participants re-
universal human experience and a very dynamic and painful quired adequate psychological support from their families and
event. When a loved one dies, one is left to grieve for the loss organizations to improve their ability to cope with the death of
(Morrissey & Higgins, 2021). The various emotional re- a coworker. The absence of support can increase perceived stress.
sponses related to death found in this study, including ner- Previous studies have shown that support from families, or-
vousness and confusion, shock and denial, deep sadness, ganizations, and supervisors received by nurses can effec-
self-blame, anxiety, and fear, are in line with a previous study tively reduce their perceived stress (Y. Zhang et al., 2020).
on nurse responses to patient deaths by Khalaf et al. (2018), Organizations must provide training to increase knowledge
who found nurse reactions to loss to include sadness, crying, of relevant coping strategies among nurses, especially those
angry, shock, denial, and feelings of guilt. who have experienced the loss of a coworker during the pan-
Although nurses are expected to offer information, guid- demic. Studies have shown that nurses with a better understand-
ance, and emotional support to patients and their families be- ing of coping strategies are better able to control their emotional
fore and after death, losing a loved one has a profound effect stress (Wazqar et al., 2017). Effective coping strategies and sup-
on their own emotional status that is difficult to control port provided to nurses can encourage nurses to extricate them-
(Makwana, 2019). Nurses experience the loss of life and wit- selves from their problems and start a new way of life.
ness the pain and suffering of the dying and the sorrow for Another theme revealed in this study is that the loss of a
the bereaved. For nurses, especially in environments such as coworker led participants to rethink and change their own
emergency departments and intensive care units where the fo- course in life. The participants in this study chose to honor
cus is on preserving life, death can represent failure and thus their deceased colleagues, reset their life goals, and enhance
be a source of stress (Jackson et al., 2020). their own health. In this phase, nurses enter a period of ac-
Deaths among nurses naturally heighten feelings of tragic ceptance and understand that life can and will go on (Oates
loss for those left behind. Of all human experiences, death is & Maani-Fogelman, 2021). In this stage, life habits may be
the most painful and far-reaching emotional adaptation chal- rearranged. While listening to their own needs and develop-
lenge for families. Failure to manage feelings of grieving can re- ing forward, nurses have not forgotten their departed com-
sult in an increase in complicated grief, also known as persistent rade, as the bereavement phase can persist for multiple years
complex bereavement disorder. This is a phenomenon charac- (Mughal et al., 2022). Previous studies have shown that the
terized by long-term and severe painful emotions that cause process of adjusting to the loss of a loved one often involves
an individual to face difficulties in recovering from their loss conducting activities such as celebrating birthdays, praying,
and continuing everyday life as normal (Duffy & Wild, 2017). and trying to live a healthier life (Entilli et al., 2021).
When experiencing emotional stress, nurses try to pursue
coping strategies such as working hard and conscientiously,
venting their emotions, reflecting and improving the quality Limitations
of work, accepting the loss, and implementing self-control. This qualitative research has limitations that must be acknowl-
Coping developed by nurses may be seen as an effort to reduce edged. First, this study focused on a small sample of nurses. To
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The Journal of Nursing Research Petrus Kanisius SIGA TAGE et al.
generalize the findings and help improve the grief problems Author Contributions
experienced by nurses in general, future studies should use
Study conception and design: All authors
qualitative and quantitative methods on much larger and
Data collection: PKST, HMAD
more-representative samples. In addition, interviews should
Data analysis and interpretation: All authors
be conducted face-to-face for optimal communication of mean-
Drafting of the article: PKST, YMKL
ings. Finally, some of the findings of the participants may have
Critical revision of the article: HMAD, MYB, PKST
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