Time for personal reflection helps clinical staff cope with loss.

Takeaways

• Dealing with the death of a patient can be stressful, especially for new nurses.
• Taking the time to personally reflect after the death of a patient can contribute to a healthy work environment and promote a sense of purpose.

By Tina M. Mason, MSN, ARNP, AOCN, AOCNS, and JoEllen Warnke, MS, RN, OCN

A common source of stress for nurses in oncology is the death of a patient they’ve cared for over a long time. Relationships develop between the clinical staff and the patients and families, making the deaths difficult for some nurses. For example, a study by Mohammad Naholi and colleagues found that one of the most stressful factors for new oncology nurses was dealing with death and dying.

This stress can affect new oncology nurses’ job satisfaction, desire to stay in nursing, and physical and psychological health. But Hildebrandt notes that oncology nurses are frequently excluded from grief-resolution activities.

This article describes a strategy for helping staff take the first step in resolving grief.

Nursing residents take the lead

Moffitt Cancer Center has a yearlong oncology nurse residency program to promote the specialty and to help nurses transition into practice. Newly licensed nurses complete classroom activities and hands-on skills demonstration, including simulation.

Questions about dealing with death and dying arise with all of the residency groups, especially related to patients with longer lengths of hospital stay. After sharing personal experiences of patients’ deaths, one residency group turned to the literature to find ideas for helping clinicians cope with grief.

The literature search revealed four key strategies for grief resolution:

• creating a positive work environment
• debriefing with colleagues
• providing end-of-life education and grief training
• altering patient care assignments.

After evaluating possible strategies for assisting in grief resolution, the team embraced the Pause, as described by Jonathan Bartels, RN, at the University of Virginia Health System. Bartels describes the Pause as a time to slow racing minds, offering mental space so staff members aren’t drawn into the vortex of failure versus success.

The residency team surveyed 70 interdisciplinary staff members (nurses, technicians, providers, chaplains, managers, social workers, and educators) about their level of distress and ability to cope after a patient’s death. Seventy-five percent of nurses said they experienced distress, and 80% said they were able to cope. However, 90% of nurses and 88% of all staff surveyed said they would benefit from a moment of silence immediately after a patient’s death. The results of the survey prompted the team to advocate for the addition of in-the-moment processing after a patient’s death.

Process success

The residency team modified the Pause to fit its vision. The process includes posting a painting of a sunset, created by artist-in-residence Carol Shore, on the deceased patient’s door and notifying the chaplain staff. After staff members gather at the patient’s room, the chaplain reads a reflections script, which is followed by a 30-second silence and closing words. (See The Pause guidelines.)

The Pause was well received by the center’s patient and family advisory council, nursing executive leadership, and coordinating practice council. After staff education, it was implemented in February 2016 and has been expanded to the ambulatory setting. Reminders are shared at governance meetings to ensure that the process continues to receive support.

The Pause has received positive feedback from participating staff, including the following comments:

The Pause Guidelines

The following guidelines were established for using the Pause to acknowledge patient deaths and allow staff time to reflect. Definition: The purposeful act of stopping (to take a Pause) to honor a patient who has expired, to recognize this person together in our own way and in silence, to allow our racing minds to slow, and to offer a mental space so that we are not drawn into the vortex of failure. —Jonathan Bartels, RN, the University of Virginia Health System Key points: 1. The Pause is optional. 2. A concerted effort will be made to notify all appropriate staff so that each may make a decision whether to participate. 3. Offer the Pause to the family at the bedside. If the family

declines, a Pause can occur after the family leaves or in another location to meet the needs of the staff. Process (inpatient setting): After a patient’s death: 1. Primary RN or health unit coordinator (HUC) notifies all appropriate staff that a Pause will take place. 2. Primary RN or HUC notifies chaplain staff via SmartWeb; include extension number, unit name, the Pause (message). 3. Place sign on patient’s door (painting of sunset). 4. Begin the Pause. 5. Chaplain or assigned staff leads the time of reflection. 6. Pause and reflect, followed by 30 seconds of silence. 7. Chaplain or assigned staff closes the Pause and replaces the sign in the designated area.

Process (ambulatory setting):  After learning of a patient’s death: 1. Primary RN notifies manager of request for the Pause. 2. Primary RN or patient service specialist (PSS) notifies all appropriate staff that a Pause will take place. 3. Primary RN or PSS will notify chaplain staff via SmartWeb; include extension number, area name, the Pause (message). 4. Place sign on door (painting of sunset) of break room or other selected area. 5. Begin the Pause. 6. Chaplain or assigned staff leads time of reflection. 7. Pause and reflect, followed by 30 seconds of silence. 8. Chaplain or assigned staff closes the Pause and replaces the sign in the designated area.

Reflecting on honorable care

After the death of a patient, the Pause allows staff who cared for the patient to stop and reflect on their contributions to the patient’s life as honorable and not as failure. Support of pastoral care is vital to helping the interdisciplinary team cope with a loss. The Pause is one way to contribute to a healthy work environment, bringing healing and a sense of purpose to the members involved.

Tina M. Mason is a nurse researcher and JoEllen Warnke is a manager of nursing professional development at the Moffitt Cancer Center in Tampa, Florida.

Selected references

Bartels JB. The pause. Crit Care Nurse. 2014;34(1):74-5.

Gomes B, Higginson IJ. Where people die (1974-2030): Past trends, future projections and implications for care. Palliat Med. 2008;22(1):33-41.

Hildebrandt L. Providing grief resolution as an oncology nurse retention strategy: A literature review. Clin J Oncol Nurs. 2012;16(6):601-6.

Mohammed Naholi R, Nosek CL, Somayaji D. Stress among new oncology nurses. Clin J Oncol Nurs. 2015;19(1):115-7.