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ORIGINAL ARTICLE The Journal of Nursing Research ▪ VOL. 31, NO.

3, JUNE 2023
DOI: https://doi.org/10.1097/jnr.0000000000000554

“Suddenly Feeling Dark”: A Qualitative Study


on the Experiences of Nurses Facing Coworker
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Death During the COVID-19 Pandemic


Petrus Kanisius SIGA TAGE* • Herliana Monika AZI DJOGO • Yulia M. K. LETOR
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Maria Yoanita BINA

comprehensively. This study emphasizes the importance of de-


ABSTRACT veloping strategies to help nurses cope positively with their
Background: The coworkers of nurses who died because of grief from a holistic perspective, which may be expected to im-
COVID-19 infection generally experience a highly emotional pact positively the performance of nurses.
grieving process. Nurses grieving the loss of a coworker during
the COVID-19 pandemic experience higher psychological KEY WORDS:
stress because of their high workload and the grueling shifts re- COVID-19, death, grief, nurse, qualitative research.
quired to manage health emergencies during the pandemic and
cope with long-standing staffing shortages. The limited number
of studies discussing this issue has resulted in insufficient evi-
dence necessary to develop effective counseling strategies Introduction
and psychological support for nurses in Indonesia dealing with Nurses have important roles and responsibilities during the
the massive waves of COVID-19 cases. COVID-19 pandemic and continue to be at the forefront of
Purpose: This study was designed to elucidate the experiences patient care and of interacting with patients infected with
of nurses across four provinces in Indonesia who had experi- COVID-19 (Schroeder et al., 2020). Thus, nurses face a high
enced the loss of a colleague during the COVID-19 pandemic. risk of COVID-19 infection (Fernandez et al., 2020). One re-
Methods: A qualitative research design and phenomenological
port identified that 38.6% (59,014) of the 152,888 health-
approach were used in this study. Sampling was done in Ja- care workers infected with COVID-19 in 2020 worldwide
karta, Bali, East Java, and East Nusa Tenggara using purposive were nurses (Bandyopadhyay et al., 2020). The consequence
sampling for the first eight participants and snowball sampling of a severe COVID-19 infection is death. According to the In-
for the subsequent 34 participants. Semistructured, in-depth in- ternational Council of Nurses, in January 2021, the number
terviews were used to collect data from 30 participants using of nurse deaths globally because of confirmed infection exceeded
appropriate ethical principles. Data saturation was achieved af- 2,710 cases (International Council of Nurses, 2021) and, in
ter interviewing 23 participants, and their data were analyzed Indonesia, up to 339 nurses have already died because of
using thematic analysis. COVID-19 (Databoks.katadata.co.id, 2021).
Results: Three main themes related to nurses' responses to The death of a nurse is known to trigger a grieving process
the death of a colleague, distinguished into several stages, with a strong emotional response among their coworkers (Kostka
were identified. Stages in the first theme were as follows: (a) et al., 2021). Mughal et al. (2022) explained that grieving is
shocked to hear of colleague's death, (b) self-blame for failing an outward expression of grief influenced by cultural and re-
to save a life, and (c) afraid to experience the same situation. ligious customs around death and the process of adapting to
Stages in the second theme were as follows: (a) make efforts life after loss. Although grieving is a normal human response
to avoid the same thing from happening again, (b) develop strat-
that should not be considered a psychiatric disorder, the World
egies to avoid thoughts of loss, and (c) expect to have a psycho-
Health Organization's (2020) International Classification of
logical support system. Stages in the third theme were as fol-
lows: (a) seek new reasons, goals, directions, and meanings in Diseases, 11th Revision classifies the problem of grieving with
life and (b) improve the physical and social health of individuals.
MSN, RN, Lecturer, Health Sciences Faculty, Department of Nursing,
Conclusions/Implications for Practice: The range of responses University Citra Bangsa, East Nusa Tenggara, Indonesia.
from nurses to the death of a colleague during the COVID-19
Copyright © 2023 The Authors. Published by Wolters Kluwer Health,
pandemic identified in this study may be referenced by service Inc.
providers to better provide psychological assistance and sup-
This is an open access article distributed under the Creative Commons
port to nursing staff. In addition, the coping strategies described Attribution License 4.0 (CCBY), which permits unrestricted use, distri-
by the participants provide detailed information that healthcare bution, and reproduction in any medium, provided the original work is
providers may use to deal with nurses facing death more properly cited.

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

Data Analysis Furthermore, decision making at each research stage was


documented for tracking and follow-up actions.
Following Braun and Clarke (2006), thematic analysis was
used to accurately capture the grieving experience of each
participant. The analysis process begins with the researcher
Ethical Considerations
familiarizing themself with the data by listening to each inter- Ethical approval was obtained from the Citra Bangsa University
view tape before transcription. Four researchers heard the re- Committee, Kupang, Indonesia (reference number: LB 02.03/1/
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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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One participant tried to suppress their emotions in the face of


As he was dying during the chest compression process, it the death of a coworker and only vented negative feelings af-
tugged at my heartstrings. I'm worried that the compression ter the process was complete. The participants also revealed
action I'm doing is too slow or I'm doing it wrong. When the that turning to religious beliefs helped them rationalize the
rescue failed, my hands were still shaking. (Nurse 13) loss and life after death.
I did some sports, learned to dance, and cared for cats. I
Self-blame for failing to save a life get flooded every day. Staying busy allows me to forget my
The participants “self-stigmatized,” self-perceiving themselves dead co-workers. (Nurse 4)
as “losers,” “unfaithful people,” “unlucky,” and “bitter” for If I feel broken, I pray to release it, and I believe good peo-
failing to save the lives of their comrades. ple will live in peace in heaven. (Nurse 17)
The person closest to my life has left me; I don't want to
live in the world. I was the one who failed to help him when Expect to have a psychological support system
he needed me. (Nurse 6) Nurses face great psychological stress when dealing with the
I feel unlucky, and I'm not a good friend. I thought I did death of coworkers and desperately need the understanding
not have the face to meet my best friend after death. (Nurse 18) and support of those closest to them. After witnessing death,
nurses feel physically and mentally exhausted and need
emotional help.
Afraid to experience the same situation Sometimes I tell my family about my best friend's death,
The COVID-19-related death of coworkers made nurses feel and they say I'm pessimistic and I don't like hearing it. I want
anxious and afraid that they may also experience a similar them to empathize with me. (Nurse 19)
fate. The expressions of fear conveyed by the nurses relate Usually, I comfort patients and their families by being
to a traditional Indonesian belief that people who have died more open-minded and optimistic. However, when I am de-
will haunt those still living. pressed, there is no one to comfort me. I am forced to let the
I am a single parent and have a small child at home who feeling fade with time. (Nurse 13)
needs my attention; I am worried that if I get infected with
COVID-19 and die like my colleague, there will be no one Theme 3: Responses in the Third Stage
to take care of my child. (Nurse 2)
My colleague who died was my best friend since child- Seek new reasons, goals, directions, and meanings
hood. We were not married and lived together in a rented in life
house when he died. I was afraid and had to flee to my
Resetting life goals refers to rearranging one's life based on
brother's house, but he is still always present in my dreams
the wishes of a deceased friend, the wishes of others, or per-
to this day. (Nurse 14)
sonal expectations. In other words, the participants sought
out new reasons, purposes, directions, and meanings in life.
Theme 2: Responses in the Second Stage They also expressed that they valued their deceased colleagues
as showing the way to a new life path through continued
Make efforts to avoid the same thing from bonding with material means and spiritual connections.
happening again I thought about what my best friend said when he was
The participants reported feeling sorry for the death of their co- alive about continuing my education. Now I am preparing
worker and making concerted efforts to prevent the same thing for it (continuing education). (Nurse 11)
from happening to others. They focused on their work and We once intended to do charity in an orphanage. Now, I
treated every patient with COVID-19 with the utmost care. In do charity. This is also a way to fulfill my best friend's wish.
addition, some of the participants repeatedly reminisced about (Nurse 4)
the death of their colleague and their mistakes and worked to
improve their efforts to prevent deaths from COVID-19. Improve the physical and social health of individuals
The most important thing is to keep working and not make Improving health refers to the maintenance and improve-
mistakes. We must have a clean conscience when dealing with ment of physical and social health. The participants sought

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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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loss-related sadness that allow them to focus on improving


the quality of work and working more carefully. The findings
Discussion in this study align with M. Zhang et al. (2021), who examined
The participants displayed eight subthemes in three stages to nurses' coping strategies during the home isolation period for
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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

5
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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been influenced by the Indonesian cultural context. Thus,


further studies should be conducted in other country and so-
cial settings to examine similarities and differences. Received: December 8, 2021; Accepted: June 15, 2022
*Address correspondence to: Petrus Kanisius SIGA TAGE, MSN, RN,
X1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 03/26/2024

Kayu Putih, Oebobo, Kupang, East Nusa Tenggara 85111, Indonesia.


Conclusions Tel: +62 0380 8553961; E-mail: petruskanisiussigatage@ucb.ac.id
The authors declare no conflicts of interest.
The experience of nurses facing the death of a coworker in this
study included several stages of responses. First-stage responses Cite this article as:
included (a) shocked to hear of colleague's death, (b) self-blame Siga Tage, P. K., Azi Djogo, H. M., Letor, Y. M. K., & Bina, M. Y. (2023).
“Suddenly feeling dark”: A qualitative study on the experiences of
for failing to save a life, and (c) afraid to experience the same sit-
nurses facing coworker death during the COVID-19 pandemic. The
uation; second-stage responses included (a) make efforts to Journal of Nursing Research, 31(3), Article e273. https://doi.org/
avoid the same thing from happening again, (b) develop strate- 10.1097/jnr.0000000000000554
gies to avoid thoughts of loss, and (c) expect to have a psycholog-
ical support system; and third-stage responses included (a) seek
new reasons, goals, directions, and meanings in life and (b) References
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