UNIVERSITY OF GHANA COLLEGE OF HUMANITIES DEPARTMENT OF PSYCHOLOGY PATIENT LOSS, COPING AND RECOVERY; A QUALITATIVE STUDY OF LIVED EXPERIENCES OF INTENSIVE CARE UNIT NURSES IN SELECTED HOSPITALS IN GHANA EBENEZER TAWIAH KORLI 10412532 THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON, IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF MPHIL IN PSYCHOLOGY DEGREE JUNE 2022 Page | 56 Page | ii DECLARATION This is to certify that this thesis is the result of research carried out by EBENEZER TAWIAH KORLI towards the award of the MPhil Clinical Psychology Degree in the Department of Psychology, University of Ghana. ……………………………………………………… EBENEZER TAWIAH KORLI (STUDENT) 27th June 2022 ………………………………………… ………………………………..... ………………………………….. DR. JOHNNY ANDOH-ARTHUR DR. JOANA LARRY-AFUTU (PRINCIPAL SUPERVISOR) (CO-SUPERVISOR) 27th June 2022 27th June 2022 …………………………………. ………………………………… DEDICATION I wish to dedicate this thesis to my octogenarian father, Mr. Robert T. Korli, who has braved the scourge of ill-health in recent times. His journey has been an inspiration to me. To my mother, Mrs. Elizabeth Korli, for her priceless pieces of advice and support. To my elder siblings Sophia, Michael, Nathaniel, and nephew Roland, for their unflinching love and support throughout the entire study period. Finally, I wish to dedicate this work to The Church of Pentecost, Housing Down District, English Assembly, where I am an Elder, for their prayers and best wishes. ACKNOWLEDGEMENT All thanks to God for how far he has brought me. I would like to express my profound gratitude to my supervisors Dr. Johnny Andoh-Arthur and Dr. Joana Larry-Afutu for their patience with and support for my thesis. I could not have made it this far without them and I am forever grateful to them. I would also like to express my sincere gratitude to the various lecturers in the psychology department, whose stimulating lectures and conversations birthed the concept behind this work. I would like to make special mention of my colleague and friend Crescens Ofori, who has been of tremendous help to me. To my family and friends who have kept faith in me, supporting and encouraging me throughout the course, I say a big thank you. God richly bless you all. TABLE OF CONTENTS DECLARATION i DEDICATION ii ACKNOWLEDGEMENT iii TABLE OF CONTENTS iv LIST OF TABLES vi ABSTRACT vii CHAPTER ONE 1 INTRODUCTION 1 1.1 Background to the study 1 1.2 Problem Statement 4 1.3 Aims and Objectives 6 1.4 Relevance of the Study 6 CHAPTER TWO 8 LITERATURE REVIEW 8 2.1 Introduction 8 2.2 Theoretical framework 8 2.2.1 Emotional labour theory 8 2.2.2 Grief/Bereavement theory 10 2.2.3 The job demand resource model 11 2.2.4 Stress and Coping Model 12 2.3 Review of related literature 13 2.3.1 Disenfranchised Grief 13 2.3.2 Emotional impact of patient death 14 2.3.3 Expectation and Responsibility 15 2.3.4 Effects on personal life and professional performance 16 2.3.5 Interventions and coping strategies 17 CHAPTER 3 19 METHODOLOGY 19 3.1 Introduction 19 3.2 Study Design 19 3.3 Interpretative Phenomenological Analysis 19 3.4 Research setting 21 3.5 Sampling and sample size 21 3.5 Procedure for recruiting study participants 22 3.6 Pilot study 23 3.7 Data collection/materials 23 3.7 Ethical considerations 24 3.8 Data analysis 25 CHAPTER 4 29 RESULTS 29 4.1 Introduction 29 4.2 Demographic characteristics 29 4.3 Nurses Memories of Experience of Patient Death 31 4.4 Psychological impact 37 4.3.3 Coping strategies 41 4.3.4 Administrative structures 44 4.3.5 Recovery 45 4.3.6 Capacity to manage experience 47 CHAPTER 5 50 DISCUSSION 50 5.1 Introduction 50 5.2 Nurses memory of the experience of patient death 50 5.3 Psychological impact of patient death experience 51 5.4 Coping strategies 52 5.5 Administrative structures 53 5.6 Recovery 54 5.7 Capacity to handle experience 54 5.8 Limitations 55 5.9 Recommendations for future research 55 5.9.1 IMPLICATIONS OF FINDINGS 56 5.9.2 CONCLUSION 56 References 58 Appendix 63 LIST OF TABLES Table 1: 28 Table 2: 29 ABSTRACT The experience of patient death is a usual phenomenon in the hospital setting. Caring for, and being close to critically ill and dying patients elicits intense emotional and psychological reactions and can result in burnout among nurses. A review of the literature shows that little is known about the lived experiences of nurses concerning patient death. The study sought to explore the lived experiences of Intensive Care Unit (ICU) nurses concerning patient loss, coping, and recovery from the experience. A qualitative design with semi-structured interviews was adopted. Twenty-five (25) ICU nurses were purposively and conveniently sampled from the Greater Accra and Eastern Regional Hospitals. Participants included 4 male and 21 female nurses between the ages of 23 and 42 with a standard deviation of 29.2. Data gathered was analyzed using the Interpretative Phenomenological Analysis (IPA). Six superordinate themes were gleaned from the data gathered. These are nurses’ memories of the experience of patient death, psychological impact, coping strategies, administrative structures, recovery, and capacity to handle the experience. The participants’ memories of patient death experiences hinged on their painful memories, the condition of the patients and their emotional reaction to the experience. The patient death experience was found to result in emotional numbness, competence questioning, and an awareness of one’s mortality. The participants’ coping strategies, administrative structures available for them, the process of recovery, and their capacity to handle the experience effectively were also explored. It is recommended that nursing training and administration consider insights from this thesis to put in place measures to better position nurses to handle patient death in healthcare facilities. This study provides vital information to clinical psychologists regarding the psychological and emotional impact of the experience and a basis for the design of effective interventions for addressing such experiences associated with patient deaths. CHAPTER ONE INTRODUCTION 1.1 Background to the study Medical health professionals are responsible for the constant care, treatment, and ensuring welfare, recovery, and survival of patients from various ailments. Improvements in medical science and technology have been done to prolong the lifespan of human beings and improve their quality of life (Khalaf et al., 2017). Over the years, groundbreaking research work has been undertaken for this purpose. Despite these advances, various chronic diseases, accidents, and viral and bacterial infections continue to claim lives (Sansone & Sansone, 2019). This study explored the lived experiences of intensive care unit (ICU) nurses about patient loss, and how they cope with and recover from the phenomenon. Healthcare service providers can be categorized among the class of workers who are exposed to higher levels of stress, depression, and burnout as compared to members of other professions (Whitehead, 2012). They are responsible for making medical decisions concerning what treatment options will be best, monitoring patients, and collaborating or consulting with other professionals on diagnosis and treatment among others. Making the right decision in this setting is often crucial as lives are at stake. The nature of their work is such that they are usually close to critically ill, dead, or dying patients (Jonas-Simpson et al., 2013). As a result of the above, the work of doctors, nurses, and other healthcare workers is evaluated as being physically and emotionally demanding (Kinman & Leggetter, 2016). Brink et al (2012) argue that healthcare service providers such as nurses and midwives are engaged in an occupation that involves a significant amount of emotional regulation and management. Similarly, research by Bagdasarov and Conelly (2013), points to the fact that the working environments in which healthcare workers perform their duties are often strenuous. Over the years, considerable efforts have gone into the study of stressors in the area of healthcare provision (Brotheridge, 2006; Lartey et al., 2019;). There has been a fundamental need to know and understand the sources of stress in healthcare providers. These include factors that could lead to stress such as poor working relationships with patients and other colleagues, workload, gross understaffing, and strained communication with patients’ relatives among others (Grandey, 2000). The job demand resource model indicates that the stressors within the work environment place physical, emotional, and psychological pressures among others on employees (Bakker & Demerouti, 2007). Almost all the professionals working within the healthcare provision service experience some form of stressor, even though it must be noted that these differences in the levels and impacts that these stressors have on the professionals (Williams, 2007). For instance, a laboratory technician may interact with a fewer number of patients and family members compared to a nurse, hence the impact of stress may be low comparatively. Nurses go through a wide range of emotional situations. These might include anger, remorse, and helplessness as a result of their work roles (Hillard & O’Neil, 2010). Findings from research carried out by Gerow et al. (2010) suggest that among the sources of stress and burnout among nurses is the experience of patient death. This experience represents a substantial amount of psychological distress, arising from observing patient suffering. Even though the phenomenon of patient loss occurs often in the hospital setting, the subject is seldom discussed, a situation described as death denial (McBay, 1997). The nature of the work of nurses is such that the experience or witnessing of the death of patients is inevitable. Nurses’ reactions to patient loss encompass an inability to express their grief concerning the experience and this over time, results in significant amounts of distress. These reactions are sometimes misconstrued to be malingering as they present as absence from work, reduced productivity, and general apathy or lethargy towards work (Jebuni, 2011). The stressful nature of this experience is also a result of being near critically ill and dead patients, and also the feeling of despair at one’s inefficacy or failure to do anything about the situation. It affects their psychological and emotional well-being as well as how they perform their duties after the experience (Ali, 2017). Zomorodi and Lynn (2010) in a study of critical care nurses’ values and behaviors with end-of-life care perceptions and challenges found that the experience of patient death has a long-lasting effect on nurses even though the distress regarding the experience reduces as the nurses’ experience more and more of the phenomenon. According to Davies (2016), the severity of the effect that patient loss has on health personnel including nurses is so profound that they may never forget their first experience of patient death. They may be affected by it throughout the rest of their life and work. Studies identify nurses as having more extensive contact with patients than any other group of healthcare professionals in the hospital setting (Costello, 2001). The provision of healthcare services for critically ill patients or patients at the end of life has significant implications for intensive care units or critical care nurses (Brunelli, 2005). The stress associated with patient loss and its effect on nurses in hospitals leads to significant psychological and physical reactions (Wilson & Kishbaum, 2011). This can be seen to have an implication on health as well as satisfaction levels of nurses which eventually has an impact on the quality of care for the patients they attend to (Sansone & Sansone, 2012). 1.2 Problem Statement The phenomenon of patient death represents a common occurrence in the intensive care or critical care units. In Ghana, some studies have been done concerning stress and burnout among nurses and other healthcare professionals (Abaa, 2013). These studies have looked at some stressors within the nurses’ working environment. Some of these include workload, barriers to optimal care, and relationships with colleagues and other healthcare professionals among others. Health workers are prone to burnout, and this negatively affects their personal and professional lives (Odonkor & Frimpong, 2020). Studies into occupational stress among nurses also pointed to several factors in the hospital environment (Jebuni, 2001). Research indicates that patient death constitutes a significant amount of distress for the nurses who work in these units. Nevertheless, there is a paucity of research specifically concerning nurses’ lived experiences of patient death (Beckstrand et al., 2006). Nurses, more than several other professionals in the healthcare setting, by the roles, experience patient death or provide healthcare services to patients that are at the “end of life”. The effect of the experience of patient death with regards to nurses is not all distressing, however. Some studies indicate that caring for patients at the end of life can be very rewarding psychologically (Charalambous & Kaite, 2013). They suggest that nursing staff experience a sense of contentment knowing that they have been able to provide the best form of care and also that the patients passed away while experiencing little or no pain or discomfort. Some other research findings, however, show that nurses have significant difficulties dealing with patient death (Edo-Gual et al., 2014; Parry, 2011; Sadala & da Silva, 2009; Strang et al., 2014) and are often unprepared for this experience (White & Coyne, 2011). Studies by Petrites et al. (2016) also found that stillbirths and infant deaths are stressful and traumatic for physicians and midwives. To provide effective and efficient healthcare services they are supposed to be prepared for the emotional, physical, and mental demands accompanying patient death. In a study of nursing students’ experiences, Deffner and Bell (2005) found feelings of helplessness, guilt, and distress while caring for dying patients and as a reaction to the death of patients. The researcher thus set out to explore the lived experiences of intensive care unit nurses concerning patient loss, and how they cope with and recover from the phenomenon. The focus on intensive care units is because the ICU is one of the common healthcare specialties where the mortality rates are high (about 19.1% to 21.8%) and hence can provide adequate perspective for the study (Batley et al., 2017; Shorter & Stayt, 2009). Also, deaths recorded in the ICU were found to include sudden deaths and the death of young and previously healthy patients. These have been noted to elicit strong emotions of distress, guilt, and grief among intensive care unit nurses. The nature of nurses' experiences with patient death in Ghana had to be explored and understood in terms of how it affects them and how they deal with the experience. The focus of similar studies has been on the workload of nursing staff and burnout, which affects the performance of their duties as well as personal lives. The gap in the literature regarding nurses’ experiences with patient death is the paucity of research into the psychological experiences of the nurses regarding the experience of patient death. This study as a result aims at exploring these experiences, and the coping mechanisms the nurses adopted as well as recovery. 1.3 Aims and Objectives The main aim of this study is to explore the lived experiences of ICU nurses concerning patient death. However, the specific objectives are the following; 1. To explore ICU nurses’ lived experiences of patient death in selected hospitals in Ghana. 2. To explore how a patient’s death affects ICU nurses in the selected hospitals. 3. To explore the coping mechanisms employed by ICU nurses in the management of the effects of patient death. 4. To explore support services available to ICU nurses in selected hospitals. 5. To explore recovery from the experience of patient death among ICU nurses in the selected hospitals. 6. To explore the ICU nurses’ perceptions about the adequacy of their training in the management of the effects of and reactions to patient death. 1.4 Relevance of the Study The study will be key in providing vital information to psychologists, hospital administration, nursing administration, doctors, nurses and staff as well as students as to the psychological, physical, and emotional effects that patient death has on nursing staff and the various therapies, administrative directives/policies that are effective in providing help to nursing staff. Such insight will also be instrumental in building the capacity of nursing staff to provide better quality service to patients. Another significance of this study is that the knowledge that will be gained from it as well as similar studies will influence nursing practice concerning the various measures that need to be followed administratively after patient loss. Insights from the study will also contribute to enriching the quality of nursing training syllabi and course materials. Finally, this study and its findings will add to the body of knowledge in the fields of psychology as well as nursing concerning understanding patient death and the effective management of related emotional labour identified by research. CHAPTER TWO LITERATURE REVIEW 2.1 Introduction This chapter begins with the presentation of theoretical frameworks: Emotional Labour Theory by Alicia Grandey (2003), Grief Theory, Job Demand Resource Model by Bakker & Demerouti, (2007), and the Stress and Coping Model by Lazarus and Folkman (1984) which were used to guide the study. Since this study was conducted among intensive care unit (ICU) nurses with regards to their lived experiences of patient death, the theories are followed by a presentation of some literature on disenfranchised grief, emotional impact of patient death, expectation, and responsibility, effects on personal life and professional performance, intervention, and coping strategies. 2.2 Theoretical framework 2.2.1 Emotional labour theory Nursing practice is heavily immersed in emotion-related situations and as a result, emotional labour forms a core part of the nursing experience (Msiska et al., 2014). These emotion-related situations include nurses’ relationships with supervisors, colleagues, and patients, chronic conditions of patients, and patient loss among others. According to Kinman and Leggetter (2016), the physically and emotionally demanding nature of these conditions can lead to sadness and job burnout among nurses. The emotional labour theory explains how individuals respond to or deal with such situations. Propounded by Grandey (2003), the theory posits that to display desired emotions at work, employees either hide felt emotions or try to express the desired emotions. In the work environment, nurses are expected to express positive emotions even if this might not represent their internal state. In his paper When the show must go on: surface acting and deep acting as determinants of emotional exhaustion and peer-rated service delivery, Grandey (2003) outlined two strategies that employees adopt as they attempt to express the desired emotions at work. These strategies are surface acting and deep acting. Surface acting refers to suppressing internally felt emotions to express organizationally desired emotions while deep acting is the expression of emotions that are consistent with internally felt emotions. In other words, surface acting is simply masking one’s psychological distress and putting up an “act” that is incongruent with internally felt emotions. This could also be referred to as faking. Deep acting on the other hand has to do with the expression of internally felt emotions outwardly. In contrast with the “faking” that occurs in surface acting, deep acting can be considered as “being real” with one’s emotions. With regards to nurses and the experience of patient death, deep acting would be seen in behavior such as crying, fear, and avoidance of patients among others. The general understanding or basis for this is the fact that workers are supposed to express positive emotions at work and an inability to do so would mean that one had to hide felt emotions. With intensive care unit nurses, surface acting would mean that they suppress internally felt psychological distress, sadness as well as any difficulties they have with the experience of patient death and continue normally. To understand the implication of these strategies, a study by Lartey, Osafo, Andoh-Arthur & Asante (2019) found that the suppression of internal emotions can result in emotional dissonance and inner tensions that can affect the work of the employee. In recent times, the concept of emotional labour has become a subject matter of interest among researchers, especially in the domains of psychology and administration (Ashforth & Tomiuk, 2000; Grandey, 2000; Grandey, Tam, & Brauburger, 2002; Zapf, 2002). There are, however, some assertions that indicate that staff can express appropriate emotions devoid of surface or deep acting as indicated by the theory (Brotheridge, 2006). The proponents of these assertions opine that employees can perceive, understand and manage their emotions and that of others (Bradberry & Greaves, 2009; Mensah & Amponsah-Tawiah, 2014), a skill referred to as emotional intelligence. Since their work entails emotion-related situations, Brink et al, (2012) suggest that emotional intelligence, rather than surface or deep acting, should be the core responsibility of nurses and midwives. 2.2.2 Grief/Bereavement theory The phenomenon of grief is an all-too-common though rarely discussed topic as it elicits various emotional reactions from people. Buglass (2010) defines grief as a natural human response to separation, bereavement, or loss, and in particular, the loss of a loved one. Grief is a significant human experience (Pilkington, 2006) and is of utmost interest to psychology. Dealing with how loss should be managed in his book Mourning and Melancholia (Freud, 1961 as cited in Granek, 2010, p. 46), Freud prescribed psychological intervention in a process he called “grief work”. For Freud, this process involved stages that resulted in cutting ties with the dead. Recent social constructionist views posit that continuing healthy bonds are resources for enriched functioning (Neimeyer, 2001). With regards to nurses, research indicates that a level of connection is formed with patients during the provision of care and as a result nurses are affected when a patient passes on (Shorter & Stayt, 2010). As part of the practice of nursing, some rapport between the nurse and the patient is needed. This connection is necessary to understand how nurses provide optimal care for patients. In a study by Gerow et al., (2010) a nurse that was interviewed stated that the loss of a patient was a painful experience. According to her, “If we didn’t love and become attached and have a relationship, then we…we wouldn’t have to have grief. So I view it as very positive even though it is painful” (Gerow et al., 2010, p.125), suggesting that forming a connection with a patient can make the loss of that patient very difficult to handle. It must be noted however that, such a connection is necessary to provide the needed care for the patient. Simply, the empathy required for the provision of care to clients often results in greater difficulty for nurses to deal with the loss of patients. Concerning ICU nurses, the theory suggests that they experience grief as a result of the connections they need to make with their patients as they provide care for them. 2.2.3 The job demand resource model The job demand resource model postulates that the work environment entails demands that tap into the physical, emotional, psychological, and other resources of the individual (Bakker & Demerouti, 2007). The demanding nature of the work of employees can have negative effects on their performance at work. As a result, they made use of several resources to manage and cope with the demanding nature of their work. Among the various resources that nurses tap into to deal with the demands of work include psychological capital, normalization, religious resources, social support, and job security (Lartey et al., 2020). With psychological capital, the individuals believe that they are special or possess some unique qualities and that is what enables them to deal with the demands of the job. Nurses who use the normalization strategy are those who express the belief that the demands are a part of the work that they do and thus they accept the situations as they come. Some workers indicate that spiritual resources such as their faith and prayer are what enable them to deal with work demands. Support from colleagues, friends, and family also goes a long way to help individuals deal with the demands of their work. Finally, the fact that the job is what enables them to make a living is what helps them handle the various demands it comes with. The availability and efficacy of the resources have a significant effect on factors such as job attitudes among others (Bakker, 2011). Work involving taking care of patients, dealing with the family members of patients, keeping/taking medical records of patients, helping critically ill or wounded patients, and being with patients at the end of their life among others imposes the various demands mentioned above on ICU nurses. The study explored how the nurses do this specifically with regards to the experience of patient death in the intensive care unit. This theory, however, does not inculcate that aspect of the work of employees which serves as a source of positive regard for them. As indicated earlier, some studies have indicated that the care for patients, in this case critically ill patients or patients at the end of life can be psychologically rewarding. This rewarding effect of healthcare provision is not seen in the job demand resource model. This theory, concerning ICU nurses, considers the demands imposed on the nurses as a result of their work and the nurses' ability to handle these emotional and psychological demands. 2.2.4 Stress and Coping Model The transactional model of stress and coping (Lazarus & Folkman, 1984) is another framework that guided this study. It is built on the understanding that stress is not dependent on the individual alone or a stressful situation alone. Instead, stress is seen as an interaction between both the individual and the situation, thus a person-situation interaction (Zakowski et al., 2001). The stress and coping model considers an individual’s interpretation of life changes or events that are considered stressful. The impact of a stressor, as a result, depends on the thought patterns and emotions attached to that stressor, as well as any actions are taken to avoid it. Two critical processes moderate this individual-situation interaction. These are cognitive appraisals and coping. Cognitive appraisal refers to a process of evaluation where the individual decides the extent to which the stressful situation is significant as well as any likely outcomes of the situation (Holland & Holahan, 2003). Coping refers to a process of continuously changing thinking patterns and behaviors to effectively handle demands that are seen as extreme and overwhelming the resources of the individual (Lazarus & Folkman, 1984). Here, we see that coping techniques are not fixed but rather a combination of organized activities that are adopted in specific situations (Mitchell, 2004). According to this theory, coping can be seen in two forms. These are emotion-focused and problem-focused coping. Emotion-focused coping refers to whether or not an individual, in the case of this study an ICU nurse, believes that he/she does not have what it takes to handle the death of a patient. Thus, the response is dependent on the individual emotions and personal resources. On the other hand, problem-focused coping is concerned with putting in place strategies or modalities with which to handle stressful situations. With regards to patient death, problem-focused coping ill includes protocols put in place by the nurses as well as administration to manage the impact of the loss of patients on nursing staff. It is important to note that both emotion-focused and problem-focused strategies can be employed to manage the same stressful situation. To handle the effects of patient death, nurses can adopt strategies that include an evaluation of their capacity to handle the event as well as putting in place some protocols that will help manage the impact of the loss. 2.3 Review of related literature 2.3.1 Disenfranchised Grief In placing the above discussion in the perspective of nursing and providing healthcare to patients, it is important to understand that healthcare professionals are also affected by death. Research by Wilson and Kirshbaum (2011) into the effect of patient death on nursing staff concludes that the death of a patient has a significant impact on the professional and personal life of nursing staff. Patient death affects nurses and other healthcare professionals differently compared to how it affects family members. Similarly, the findings of some studies on the subject point to the fact that the death of patients influences nurses either inside or outside the workplace (Wenzel, Shaha, Klimmek, & Krumm, 2011). The significant impact that patient death has on nursing staff in the various hospitals is even aggravated since, after the experience, they have to continue to provide healthcare to other patients. Facilities could record several deaths in a day, a situation that represents considerable amounts of physical, emotional, and psychological distress on nursing staff. Furthermore, nursing staff, while on duty providing healthcare to patients, are unable to express grief in ways similar to family or friends of patients when death occurs, a phenomenon referred to as disenfranchised grief. This concept was propounded by Doka (2002). It occurs in situations in which nurses are not able to express grief emotions after a patient death passes away. This is because, after patient death, they continue with administrative reporting processes concerning the patient death. Additionally, nurses continue with their duty of helping other patients. These situational and environmental hindrances to grieving by nurses can affect them and subsequently result in work-related stress, burnout, and an increase in nurses’ turnover decisions among others (Bailey, Murphy & Porock, 2011; Shorter & Stayt, 2010). 2.3.2 Emotional impact of patient death In the review of studies into the effects of patient death on nurses, notable among the findings is the significant emotional impact the death has. A review of related literature carried out by Khalaf et al., (2017) indicates that patient death elicits intense trauma in nurses, especially their first experiences, “striking a chord”. Findings in a study conducted by Rickerson et al., (2005) with healthcare staff indicated that patient death had physical and emotional effects that affected their professional, social, and family lives. In studies by Whitehead (2014), findings indicated that patient death experiences were significant and traumatic for nursing staff. Some reactions to patient death that the studies found include guilt, distress, and grief. For the intensive care units specifically, patient death has a significant emotional impact on nurses. Studies indicate that this is because the deaths are usually sudden or unexpected. They also involve young and previously healthy patients as well as trauma cases (Batley et al., 2017). The above-mentioned study, investigating the effect of patient death on medical students in the emergency department, indicates that the impact of patient death is so significant that some healthcare professionals considered quitting their jobs, others considered changing professions, and then some others also seeking counselling services. An inability to sleep, tiredness, sadness, and disappointment were some other reactions that were identified. 2.3.3 Expectation and Responsibility After patient death, healthcare staff are often drawn into contention with regards to whether they could have done more to help the patient or to prevent death. Even though in the medical setting the majority of the diagnosis and treatment burden falls on the doctors, studies by Whitehead (2014) and Kristina et al., (2017) indicate that nurses also experience similar feelings of not having done enough with regard to the care provided to patients. Such thoughts can affect the care provided to other patients. In a quotation of a study conducted by Whitehead (2014), a medical professional described being seen as a miracle worker by patients and their families. The consequence of this is significant trauma that is felt when these patients pass on and their deaths have to be reported to their families. This is important since in the healthcare delivery profession, staff are faced with a balance of expectations of medical responsibility and the uncertainty and unpredictability of life and patient care (Whitehead, 2014). In the same study above, one participant said “…how deeply responsible I felt to be competent in that moment, and how the chance of not being able to do something, or not doing it right, is so overwhelming” (Whitehead, 2014, p. 8). From this, it is clear that the competence of these healthcare practitioners does not only emanate from the question about if they could or should have done something more for the deceased patient but also from the anxiety of whether or not actions taken in treatment might have been wrong and led to the death of the patient. 2.3.4 Effects on personal life and professional performance The death of a patient is recognized as a source of occupational stress among healthcare providers (McVicar, 2003). This is because even though death is inevitable, patient death represents a failure to prolong or save the life of the patient which is distressing to the healthcare professional. Sudden, traumatic deaths and deaths of young people are noted to be a key contributor to work stress for healthcare professionals. In a study to investigate the impact of patient death on the healthcare provider’s emotional wellbeing and the role of supportive workplace strategies, Ali (2017) found that witnessing a person going through the pain, trauma, and suffering that is associated with death has the propensity to elicit significant amounts of anxiety among healthcare providers. Such anxiety is dependent on nurses’ professional, past and present characteristics (Dunn et al., 2005). Also, an individual who frequently witnesses such occurrences is reminded of his/her mortality and this reminder can be a source of fear, anxiety, and uneasiness (Peters et al., 2013). This fear and anxiety, referred to as death anxiety (Lehto & Stein, 2009) is a feeling of dread, anxiety, or fear at the thought of death or anything to do with dying, and many healthcare providers have to deal with this anxiety due to the frequency of patient deaths which they witness. Death anxiety is not entirely negative. It can cause introspection and reflection on one’s life purpose. However, it can have a disruptive impact on mental well-being as well (Nia, Lehto, Ebadi & Peyrovi, 2016). When this happens, the quality of care and caring attitudes of healthcare providers towards patients can be severely impaired. Such impairment is problematic because it affects the nurses’ grief responses as well as their ability to manage and cope with death in the future. Another noteworthy effect of patient death on healthcare providers is a phenomenon referred to as compassion fatigue. This sense of helplessness and uncertainty is defined by Branch and Klinkenberg (2015) to be a combination of secondary traumatic stress and feelings of frustration, despair, and helplessness. Meadors and Lamson (2008) also define compassion fatigue as a loss of the ability to provide the same level of compassion to patients and their families as they have previously. According to Bush (2009), nurses and frontline healthcare workers are at a higher risk of developing compassion fatigue as a result of their close contact with patients. A challenge with having compassion fatigue is that nurses become irritable, angry, make poor decisions, exhibit poor caring attitudes, are often absent, and can sometimes resort to drug abuse (Cocker & Joss, 2016). Some others could also experience guilt and depression after the death of patients (Papadatou, 2000). The above-mentioned difficulties reflect the effects of patient death on nursing staff among the findings of various similar studies. They also denote a significant amount of distress in healthcare professionals. 2.3.5 Interventions and coping strategies In pursuit of strategies or mechanisms to cope with the above-identified effects, several measures have been put in place, according to studies that aimed at understanding coping systems used by the nurses. Studies by Aycock and Boyle (2009) identified three main avenues for helping staff to deal with the effects of patient death. These were formal teaching sessions, less formal staff meetings, and finally retreats in the form of taking some time away from the ward for staff to share experiences and provide support to each other. Formal teaching sessions usually take the form of teaching and orientation of nurses specifically regarding the phenomenon of patient death while they are being trained for the nursing profession. Thus, as part of the curriculum of nursing training institutions, the phenomenon of patient death is discussed and students are provided with ways in which to handle the psychological distress it presents. Secondly, the staff meetings, according to the study, were employed while nurses practiced in hospitals and took the form of staff meetings on a regular or needs assessment basis. Staff would in this case hold meetings to discuss the loss of a patient to find out what led to the loss and also create an avenue for staff to vent any distress resulting from it. Finally, time away from the facility for counselling and education retreats where the support groups were formed and activities designed to ensure that nurses dealt well with patient death experiences. Close to the last strategy is seen in the findings of Fessick (2007) in a similar study where nurse retreats involving grief support and educational sessions are organized for healthcare staff periodically. In Spain, Ho et al (2010) indicated that education sessions on theories of grief were held for nurses by psychologists or social workers where they were helped to identify effective coping strategies to manage patient death experiences. Findings from similar studies indicated the use of more informal mechanisms (McCreight, 2004; Peterson et al., 2010; Rickerson et al., 2005; Shorter & Stayt (2009). Here, nursing staff relied on colleagues for support in the form of talking about their experiences with regard to patient death. Colleagues and friends thus served as avenues for catharsis where nurses expressed pent-up grief emotions and psychological distress. Religion as well has been found to provide a sense of coping for nurses. Some studies have suggested that nurses who have strong religious beliefs may be more accepting of death and dying (Braun et al. 2010; Peterson et al. 2010). It must be noted that no one coping mechanism has been identified by the literature to be the most effective. A study by Moores et al (2007) in England found that doctors who had received training with regards to dealing with their emotions in the face of patient death showed similar responses as those with no training, evidence of the significant nature of the effect of the experience of patient death. CHAPTER 3 METHODOLOGY 3.1 Introduction This section examines the method employed by this study. Information on the setting, population, sample size, participants and sample technique, research design, semi-structured interviews, and procedure used for the study are presented in this section. 3.2 Study Design A qualitative phenomenological research approach was adopted for this study. This is because the objective of the study was to explore the lived experiences of intensive care unit nurses in some selected hospitals in Ghana with regard to patient loss. The study approach describes an exploration of the common meaning for several individuals of their lived experiences of a phenomenon (Creswell, 2015). The design and methodology of the study, therefore, recognized the participants (intensive care unit nurses) as the experts in their own lived experiences. It has its origins in fields of inquiry that posit that human beings do not passively perceive objective reality, but rather they come to interpret and understand their world by formulating their own biographical stories into a form that makes sense to them (Brocki & Wearden, 2014). 3.3 Interpretative Phenomenological Analysis According to Smith et al., (2009), the IPA as a qualitative research approach, is committed to the examination of how people make sense of their major life experiences. It is concerned with the exploration of participants’ experiences, understandings, perceptions, and views (Reid, Flowers & Larkin, 2005). The approach offers a theoretical basis and detailed step-by-step process for how data is collected and analyzed (Chapman & Smith, 2002). Also, the IPA approach affords new and novice researchers the opportunity to explore in more detail, the lived experiences of the research participants (Alase (2017). Work that is produced after an interpretative phenomenological analysis represents the joint reflections of both the participant and the researcher. Research findings indicate that the interpretative phenomenological analysis (IPA) is being used with increasing frequency in published studies and is an applicable and useful research method in a wide variety of research topics (Brocki & Wearden, 2014). As this study seeks to study the lived experience of ICU nurses concerning patient death this approach is suitable for the collection of data for the exploration of the phenomenon under study. Finally, even though there are some studies into work-related stressors about nurses (Odonkor & Frimpong, 2020; Jebuni 2001), very little is known by way of the experiences of nurses about patient death. A qualitative phenomenological research approach, as a result, will enable access to valuable data on the phenomenon. The Interpretative Phenomenological Analysis entails three steps. The first of these has to do with the iterative reading of the text to familiarize oneself with it and come up with insights into it. Here, the researcher develops initial codes that would capture or summarize the responses provided by the participants. It breaks down the lengthy responses into a format that the researcher can work with in terms of gaining insight and taking note of key words or phrases. This refers to the textual description of the data (Creswell, 2013). The use of language and non-verbal utterances are carefully considered. In the second stage, the researcher transforms the codes into emergent themes in order to capture the essence of the responses. While doing this, reference is made constantly to the text to ensure consistency with what has been said by the participant. In the final stage, the researcher connects the various themes gleaned from the data. Themes that have similar meanings are merged into superordinate themes to help explain the emerging themes. This summary is the essence of the experience and represents the culminating aspect of a phenomenological study (Creswell, 2013). It also informs readers about the “what” and the “how” of the experience. 3.4 Research setting The research involved participants from the intensive care units (ICU) of two hospitals in Ghana. These are the Greater Accra Regional Hospital and Eastern Regional Hospital. These hospitals were chosen as they constitute regional referral centers and handle a majority of emergency cases in their respective regions. Intensive care unit nurses were chosen as the population for the study because the ICU is one of the common healthcare specialties where the mortality rates are high and hence can provide adequate perspective for the study (Shorter & Stayt, 2009; Batley et al, 2017). 3.5 Sampling and sample size A sample of twenty-one (21) females and four (4) male registered and practicing ICU nurses from 2 selected hospitals in Ghana was adopted for the study. For the study, nurses who have practiced in the ICU for 6 months and above were included. Student nurses and nurses who have practiced for less than 6 months were excluded. A detailed description of the demographics of participants is below. Smith et al. (2009) stated that “samples are selected purposively because they offer a research project insight into a particular experience” (p. 48). They further emphasized that IPA studies are conducted on relatively small sample sizes, and the aim is to find a reasonably homogeneous sample, so that, within the sample, we can examine convergence and divergence in some detail. Therefore, it was necessary to select a sample size that was manageable and also enable the phenomenon under study to be well examined for better understanding. Creswell (2005) suggested that selecting a large number of participants will result in a superficial perspective which will make it difficult for the researcher to provide an in-depth picture of the phenomenon being explored. In addition, Creswell (2012) indicated that for phenomenological research, the sample size can be between two (2) and twenty-five (25) and participants should have similar lived experiences. The process of data collection continued until each category was saturated and no new data emerged. 3.5 Procedure for recruiting study participants In the Eastern Regional Hospital, the researcher was asked to provide a proposal for the study. This was examined by the ethics department of the hospital and then approval was given for the researcher to conduct the study. A copy of the endorsed proposal was forwarded to the nurse in charge of the hospital’s intensive care unit who in turn spoke to the nurses and granted access to the researcher. From there, the researcher contacted the nurses and scheduled meetings with them depending on what time they were available for the study to be carried out. Of the nineteen participants who were sampled from the Eastern Regional Hospital, twelve face-to-face interviews were conducted in a room close to the unit, and seven were conducted over the phone. In the Greater Accra Regional Hospital, the researcher used the purposive sampling and then the snowballing sampling technique to reach the intensive care unit nurses for purpose of the study. Three face-to-face and three over-the-phone interviews were conducted as part of the study. As indicated earlier, ten of the interview sessions were carried out over telephone calls as it was difficult to reach the participants to have the face-to-face sessions. This process of data collection is similar to that which was used by Turner, Barlow, and Ilbery (2002) in their study of the experience of living with osteoarthritis from the perspective of ex-professional footballers. They used telephone interviews due to geographical limitations and acknowledged possible limitations. Due to the shift systems and schedules created as a means to reduce the number of nurses in the intensive care units at a time to observe the COVID 19 protocols, some of the participants had to be reached via phone calls. In the case of the Eastern Regional Hospital, the Ethics office acted as gatekeepers who facilitated access to the participants as this was one of their duties in the institution. Also, the nurse in charge played a key gatekeeper role in the sense that she introduced the researcher to participants and got them to participate in the study. They endorsed the research proposal submitted by the researcher, which made it easy to have access to the intensive care unit (ICU) nurses. A study conducted by Andoh-Arthur (2019) indicates that gatekeepers play a crucial role in facilitating access to research settings and participants. 3.6 Pilot study The interviews were conducted in the English language. The instrument used for the study was pretested on two (2) participants and responses were analyzed, removing and replacing unclear statements. The various participants contacted were comfortable with the use of the English language for the study and hence did not need for the instrument to be translated into a local language. The pilot study enabled the researcher to rephrase unnecessarily worded questions. The final interview guide was noted to be able to elicit in-depth information and thus suitable for data collection. 3.7 Data collection/materials Data was collected with the use of a semi-structured interview guide. The semi-structured interview was valid because it was flexible and also allowed the researcher to ask follow-up questions about interesting areas that came up (Smith & Osborn, 2007). Data collected included a questionnaire of demographics as well as data with regards to the experience by the use of an interview guide. Age, gender, qualification, religious affiliation, and years of service of the participants were recorded as part of the demographics. The materials used were a voice recorder, book, and pen. 3.7 Ethical considerations Ethical approval was obtained from the Ethical Committee of the Humanities (ECH) of the University of Ghana. An introductory letter from the Department of Psychology, University of Ghana was submitted to the administration of the hospitals for approval to collect data. Verbal informed consent was also obtained from all the participants and confidentiality was assured. The consent of participants was also sought for interviews to be audio recorded. Using a participant-centered approach, the researcher ensured that the rights and privacies of participants were protected. Further, for confidentiality, participants were instructed not to give their names, or contact numbers that might reveal their identity. Information shared by these respondents was termed confidential, thus participants were guaranteed any information from them would not be given to a third party without their authorization. The researcher asked the questions while the participants answered them. The interview lasted between twenty minutes to forty minutes for each participant. The data collection lasted for fourteen weeks, from 15th July to 31st October. Participants were also informed that they could withdraw from the study if they wished to. To ensure confidentiality and privacy of participants’ information, an appropriate and convenient location was used for the data collection. Names and other identifying information were not recorded as part of the transcripts to ensure the anonymity of participants. A benefit of this process was that it allowed participants to talk freely and openly about their experiences with regard to patient death. For participants who might have required some therapy or counselling afterward, a psychologist was available on call. Due to the requirements of the times, various protocols such as the maintenance of social distancing, regular use of hand sanitizers, and nose masks were adhered to throughout the study to prevent the spread of COVID. Interview Topics 1. ICU nurses’ experiences of patient death in selected hospitals in Ghana. 2. Impact of patient death on ICU nurses in the selected hospitals. 3. Coping mechanisms employed by ICU nurses in the management of the effects of patient death. 4. Support services available to ICU nurses in selected hospitals. 5. Recovery from the experience of patient death among ICU nurses in the selected hospitals. 6. ICU nurses’ perceptions about the adequacy of their training in the management of the effects of and reactions to patient death. 3.8 Data analysis The information gathered was transcribed verbatim and analyzed by the use of the Interpretative Phenomenological Analysis. The aim of Interpretative Phenomenological Analysis (IPA) as indicated earlier is to explore in detail how people make sense of their personal and social world and give a detailed interpretation of these experiences (Smith & Osborn, 2007). The study was analyzed following Smith and Osborn’s (2007) recommended guide for phenomenological analysis. The first step in this guide entailed the iterative reading of the transcribed data to become familiar with it or gain new insight into the data. Initial codes were then developed to capture any interesting or significant comments from the respondents. The initial codes were used to summarize, paraphrase or create connections within the responses. As proposed by Alase (2016), the lengthy and complex responses were coded into sentences to break down the responses into a format that the researcher can gain preliminary insights of. Also, key words or phrases that were repeated by participants were noted. This refers to the textual description of the data (Creswell, 2013). The use of language and non-verbal utterances were all taken into consideration. The second stage in the analysis has to do with the transformation of initial notes into emergent themes. At this stage, phrases were developed from the initial codes and these phrases capture the essence of the responses; at the same time, the researcher kept referring to the transcribed text to ensure that what the participant said was consistent with what was being reported. Finally, the IPA concludes with a stage that deals with the connecting of the themes gleaned. The emergent themes were then listed on a sheet of paper and then the researcher searched for connections between them. As the themes were identified, the researcher went through the transcript to be sure that they are presented in a way that agrees with the transcribed data from the participants. Themes that had similar meanings were merged into superordinate themes to help explain the emerging themes. This summary is the essence of the experience and represents the culminating aspect of a phenomenological study (Creswell, 2013). It also informs readers about the “what” and the “how” of the experience. 3.9 Data trustworthiness and Reflexivity To ensure trustworthiness, credibility, transferability, dependability and confirmability were applied as recommended by Shenton (2004). To ensure credibility, all interviews were voice recorded and participants’ thoughts and experiences were reflected. The interviews were conducted in conducive environments. The researcher recruited only participants who met the inclusion criteria. These participants were in the position to provide information that portrayed their experiences with patient death in the Intensive Care Unit. Rapport was established with participants. This was to ensure that trust was built and participants could open up and share their experiences. Participants were also assured of confidentiality of the information given. To get the lived experiences adequately grasped, phrases made by the participants were repeated to them during the interview to get their confirmation on whether the researcher grasped the meaning of their responses. The researcher used probing questions to gain a good understanding of the information from the participants. The data collected was reviewed and transcribed by the researcher and coding was done, with the help of an assistant. Issues that were overlooked were brought to light by the researcher and concepts that were named wrongly were corrected. Some refinements on the codes, themes, and subthemes disagreed on were corrected together with the supervisors. Furthermore, throughout the data analyses, the researcher perused text to make sure that each reflected the participants’ accounts of their experiences. To ensure appropriate transferability inferences, the information gathered was compared with previous studies conducted in similar situations. These include similar studies of nurses experiences with critically ill and dying patients like those undertaken by Whitehead (2014) and Kristina et al., (2017) indicated in the literature review. Additional information such as the number of participants involved, the data collection procedures, length of the data collection, are highlighted in the study. Confirmability refers to the extent to which a research finding reflects the experiences of participants and is devoid of researcher bias (Polit & Beck, 2010). In order to achieve confirmability the researcher sought for the lived experiences of practicing intensive care unit nurses with regards to the patient death experience. The researcher applied bracketing. The researcher did this by ensuring that his perceptions did not influence the findings of the study. The researcher also explained in detail his decision for choosing the specific research methodology guiding the research. Finally, the researcher verified from the participants whether the transcribed data represented their ideas. the Interpretative Phenomenological Analysis guide helped shape the appreciation of the experiences of the participants into various themes, making the study confirmable. The researcher is a Clinical Psychology intern. With regards to reflexivity, insights from engaging with nurses in various settings helped in the conceptualization of the paper. The orientation of the researcher, which includes the qualitative study of experiences such as trauma and suicidal ideation, coping and resilience were also instrumental in the conceptualization process. These did not however influence the analysis, interpretation and conclusion of the sindings of the study. This is due to the fact that the researcher adhered to the guide for Intepretative Phenomenological Analysis as prescribed by Smith and Osborn (2007). CHAPTER 4 RESULTS 4.1 Introduction This chapter presents the findings of the study. The first section focuses on the demographic characteristics of the participants. This will be followed by a presentation of the main themes and subthemes generated from the data. 4.2 Demographic characteristics Participants in this study were between the ages of 23 and 42 years, with a standard deviation of 29.2. Out of twenty-five intensive care unit nurses sampled for the study, 21 (84%) were females and 4 (16%) were males. The majority (n=20) of the participants were holders of Diploma certificates while the rest (n=5) were Degree nurses. With regards to the duration of work in the intensive care unit (ICU), the highest period was 12 years while the lowest was 8months. Table 1: Variables Frequency (n) Percentage (%) Sex Male 4 16 Female 21 84 Qualification Degree 5 20 Diploma 20 80 Years of Practice in ICU Below 1 year 2 8 1-10 years 18 72 Above 10 years 5 20 Summarized demographics of the participants Analysis of the transcribed data using IPA revealed six (6) superordinate themes. These are memories of the experience, psychological impacts, coping strategies, administrative structures, recovery, and perception of aptitude. The above-mentioned themes are further broken down into the following twelve (12) subthemes. Quotations from the experiences of the participants have been presented below, together with identifiers. The identifiers have been quoted, with P referring to the Participant and the number following the P referring to the participant number. The alphabet M and F refer to males and females respectively. Finally, the numbers following the gender of the participant refer to their age and the number of years they have worked in the ICU. For example, P1, F25: 3, connotes the first participant, who is female, ages 25, and has worked in the ICU for 3years. Table 2: Presentation of the superordinate themes and corresponding subthemes Superordinate Theme Subtheme 1. Memories of experience Painful recollections Patients’ conditions affecting grief Emotional reaction to the experience 2. Psychological impact Question of competence Emotional numbness Motivational impact of experience Mortality awareness and personal introspection 3. Coping strategies Informal ward discussions Inquiry into the cause of death A spiritual experience Psychological dependence 4. Administrative structures Random clinical psychological sessions 5. Recovery Psychological adjustment over time 6. Perception of aptitude Focus of training Personal adjustments to experience 4.3 Nurses' Memories of Experience of Patient Death This theme looks at how the participants recollected patient death experiences in the intensive care units. To do this, the nurses were noted to recount their first experience of patient death, the estimated age of the patient, the condition of the patient which influenced the effect of the experience on them, and then finally their emotional reactions to patient death. Painful recollections: This subtheme deals with narrations of patient death experiences from the perspective of the participants in the study who work in the ICU and had witnessed patient death many times. When asked about these experiences, most of the participants recalled their first experience of the phenomenon. “my first experience was a child. He was placed on a ventilator for some days. We did all we could but he couldn’t get better and after a week we had to let him go. So we released the child (took him off the ventilator) and it was a sad thing” (Participant 1, F25:2) This participant narrates her first experience of patient death. Her narration depicts a scenario in which a team of health professionals put in considerable effort to ensure that a young patient who was on life support would have some improvement in his condition. But this was to no avail and after some days, the patient had to be taken off the ventilator after which he passed. The narration of the participant suggests that even as the patient was not responding to treatment, the process of taking him off life support was painful to do. The quotation ends with the participant recounting the fact that the experience was significant enough to elicit feelings of sadness. “I have experienced patient death. There have been lots of them and I cannot remember the first one. Okay, there was this young guy who had a motor accident. He was young. We tried reviving him but he did not survive. I felt bad. Very bad. Because he really looked like an energetic person but now was just lying there, not being able to do anything. Sincerely, it was devastating to me and my colleagues. And also we were sad because we were thinking about his relatives.” (Participant 6, F28:5) The above participant expresses familiarity with the patient death experience due to the numerous occasions that she has witnessed the phenomenon. She was however unable to remember vividly the very first experience. Her earliest recollection was regarding a young man who had been in an accident and was badly injured. In this scenario as well, the idea of the team of nurses and personnel in the ward going through the various required protocols to help the patient is conveyed. As all these efforts did not yield any positive results and the patient passes away, the participant recollects feelings of sadness. It is important to note here, that the age of the patient, and the fact that it was apparent that he had been in good health just until the accident, was significant in the impact the loss had on the participant and her colleagues. Finally, the thought of how the deceased patient’s family would take the news of the patient’s sudden demise was another key stressor that impacted the distress that accompanied the phenomenon. From the above, we see that the participants recall their first or initial experiences of patient death when the phenomenon was explored among them. Initially, some of the participants indicated that they do not remember their first experiences. However, recollections were made shortly after the interviews began and they could tell in some detail their first or initial experiences amidst some sadness. Patient’s state affecting grief: As part of the recollections, one significant thing that the participants could recall as part of their experiences of patient death was the estimated ages and conditions of the patients. It must be noted that the deaths of the very young and also patients whose prognosis was not very bad were noted to elicit strong emotions from the participants at the time of the experience as well as during the study. “There are some of the patients who will come in, and you see that their prognosis is very bad. Technically, for those ones you don’t feel that much. But when the patient shows some signs of coming up (improving), and the condition begins deteriorating, it is disturbing. I mean when you get to that point and you realize that the patient’s condition is getting so bad and you are not getting results, it is not easy for you, psychologically, sometimes it weighs you down. It makes people feel like this work is so difficult. Because it is emotionally stigmatizing”. (Participant 4 F26:6) Here, the participant illustrates two separate instances with regard to the prognosis of the patient’s conditions. For cases whose prognoses are not too good, the grief experienced after the passing of the patient is not intense. However, there are other cases whose prognoses look good in terms of the potential for recovery of the patient, and it is these that, according to the participant, can elicit intense grief reactions from the participants. From the narration of her experience, the above participant suggests that when the prognosis of the these patients is good, there is an assumption that they will survive. As a result, there is significant distress when this does not happen and the patients pass away. Emotional reaction to experience: In the study, participants reported various emotional reactions to the experience of patient loss. These ranged from feelings of intense sadness, fear, and anger. Feelings of intense sadness resulted from the nurses’ being in close proximity to dying patients, having to witness the family reactions towards the loss of the patients as well as their own grief, considering that the deceased could as well be a relative of theirs. “As for that one, hmm. So there was this 15-year-old who got pregnant. Her boyfriend gave her a concoction. She was really young and being a female and having young sisters, you know. You tend to think about these things.” (Participant 6, F28:5) In the above narration, the participant recalls that a particular patient death experience “struck a chord” because of the similarities between the patient and the participant as well as others close to her. The emotional reaction expressed by the participant represented some frustration with an evaluation of the life choices of the patient which might have resulted in her demise. In the conclusion of the quotation, the participant stresses the potential of such experiences to result in some introspection as well. Some other participants reported having feelings of fear after the experience of patient loss. These participants indicated that the sense of fear was profound to the extent that one participant indicated that she had developed thanatophobia. In another instance, the participant mentioned the case of another nurse who was frightened and was shaking as a result. “I quite remember that last year during COVID, we lost one of our colleagues and it was really frustrating for us. Also, we treated her, so we had to go into isolation for 14 days. And it was difficult because you being home and hearing that this person has passed. Hmm you know you are living alone, there is no family member around, so you think a lot about it. I even experienced thanatophobia. I was just reading about death, and was kind of scared.” (Participant 6, F28:5) In the above quotation, the participant recalls an experience in which she and the team of nurses she works with on the ward had to self-isolate in the various apartments after a colleague who was also on admission and was treated by them was diagnosed with COVID. The apprehension associated with the virus as well as the period in which the event occurred (nationwide lockdown) resulted in the participant experiencing intense fear as she observed the mandatory period of self-isolation. The feeling of fear was further exacerbated when news reached her that her colleague undergoing treatment had passed away. From her narration, she began to experience an intense fear of death or thanatophobia, and was drawn to reading about death. “I was on a shift with a rotational nurse and then we lost a patient and I think she was kind of scared and shaking so I took her inside and counselled her from my own experience” (Participant 5 M31:9) This participant narrates a situation in which after the loss of a patient he had to assist another nurse, who was a rotation nurse and was probably witnessing patient death for the first time and was extremely frightened by the loss. From his account, the nurse was terrified as a result of witnessing the death. The participant shared his own experiences of the phenomenon in an attempt to calm the nurse down. With regards to the feelings of anger, the respondents indicated that one difficulty that is often encountered within the scope of their work is the fact that patients are often brought into the hospital late, at a time when their chances of survival are slim. According to them, it was frustrating when a death that possibly could have been avoided is not because the patient was brought in late. The theme “nurses’ memories of the experience of patient death” encompasses recollections about the participants’ first experience, the patient conditions which influenced grief responses, and emotional reactions to the experience. The participants gave detailed recollections of their first experiences of patient death, even though for some, it has been several years. In the accounts, they convey the idea of frustrations about how the loss of the patients meant that all efforts to help the patients proved futile. Also, the grief response to the phenomenon was moderated by the prognosis of each case. For cases whose prognoses were not too good, the death experience did not come with feelings of sadness as intense as they would for cases whose prognoses were fairly good. This is also the case for patients who had begun to show some response to treatment. With regards to the emotional reactions to the experience, the participants’ emotions included sadness, fear, and anger. Participants experienced sadness due to the relationships formed with the patients in the course of treatment as well as having to witness the reactions of patient relatives at the loss of the patients. Fear was reported as an emotional response for most cases especially the initial experiences as well as for cases where the participants identified with the patients on similarities such as age, and gender among others. Finally, participants recollected feeling angry in situations where avoidable deaths occurred due to the time in which the patient was brought into the hospital or some life choices of the participants which might have led to their demise. 4.4 Psychological impact The psychological impact of patient death reflects the effects of the experience on the thought patterns and behaviors of the participants. The subthemes identified include the question of competence, persistent distress due to the recurring nature of experience, motivational impact, the potential for introspection, and then also social withdrawal. These focus on how the experience of patient death significantly affects the thought patterns of the nurses. Question of competence: From the responses of the participants, it was noted that the experience of patient death often made the nurses question their competence and the ability to perform their nursing duties effectively. The participants in the study indicated that they sometimes questioned their competence when a patient death occurs. “Sometimes it psychologically weighs you down and you feel bad. That’s mainly the thing. It makes you feel like there is something that you are not doing well, or that you are not up to standard. Yes, sometimes too they even expect something like magic. You see, most of them are staff nurses and when a patient you are taking care of dies, it is like you have disappointed them. It is just like when a doctor is with me taking care of a patient and the patient dies, I feel like the doctor could have done something extraordinary, you see what I am saying? Yes, that is the same thing. So you ask, ah, what really happened? Is that all you could have done? Meanwhile yes, that is it too” (Participant 4 F26:6) The participant suggests that the psychological burden accompanied by patient loss is significant. Specifically, the participant explains that this burden stems from the fact that there is an expectation that nurses must ensure that the patients get well. He observes that this expectation is unrealistic, as death can occur despite the best efforts of the health personnel. He also considers the situation in terms of expectations placed on the health personnel either by patient relatives as well as colleagues in the unit. “You can meet a patient who has been managed by another nurse to stay alive (respond to treatment). And you also have to make sure that just as the patient was managed well and handed over to you, you must also keep the patient alive. And if that happens we say “w’aku no” (you have killed him/her). We just tease ourselves”. (Participant 8 M31:6) Here, the participant explains that there is an expectation for the nurses to effectively continue the management of patients who have been managed by others. This is the case because of the shift systems used in the wards. In this quotation, the participant suggests that, where a patient passes away when shifts change, the nurse responsible at the time is subjected to some blame and this also adds to the burden of questioning one’s competence, even though he indicates that this is done only in jest. Emotional numbness; Here, some of the participants indicated that since patient death is a usual occurrence in the intensive care unit (ICU), the feelings of distress associated with it result in a state of emotional numbness. Emotional numbness refers to the mental and emotional strategy by which individuals prevent themselves from experiencing some emotional sensations, usually of negative or depressive nature. From the study, the participants indicated that in some instances there could be several deaths per day. The nature of this experience results in a feeling of numbness to patient suffering and death. This, some participants indicated was capable of altering one’s personality. “Today you see this and you are depressed hoping it will go, but tomorrow or within 2 or 3 days another one could happen. And then it becomes your way of life” (Participant 5 M31:9) This participant explains the repetitive nature of the patient death experience. As indicated earlier, due to the nature of cases seen in the intensive care unit, prognoses of which are often not too good, the experience of patient death is common. The participant suggests finally that with time, the experience becomes a part of the individual. “As I said, this profession has sort of made me heartless. I see people dying and I don’t care. I don’t feel any sympathy or empathy, or anything. You die, you go. They carry the body away, and the next patient comes. But I was not like that before, so it is the profession that has made it so. You become so cold” (Participant 5 M31:9) In the quotation above, the participant suggests that over time, the repeated experiences of patient death have resulted in a state of emotional numbness, described by the participant in terms of heartlessness. He indicates that as a result of the current state in which he is, he believes that he has lost sympathy and empathy towards patients, and does not express any emotions when a patient passes away. He thus has gotten habituated to the experience that the experienced is normalized in his scheme of things. He affirms this in the conclusion that his emotional numbness is a result of the experiences of his exposure to patient deaths. He admits that he was not like that before probably because he was not previously much exposed to the experience and was thus highly sensitive to it then. “Especially when a patient passes on just when you are working on him/her. Sometimes there are some cases you didn’t expect a patient to die. So when the patient dies, it is not you alone. Sometimes all those working at that time. It affects all of you and you feel so down. And it makes you analyze your performance as well. It affects you even at home too. A lot. Sometimes a patient can die, when you get home you can’t even eat. You will be thinking “How did this even happen” like psychologically you are very down” (Participant 8M31:6) The participant explains that the psychological impact of the patient death experience is profound for the nurse in situations where the patient passes on while the patient is being cared for. She goes on to indicate that the loss of a patient does not only affect the nurse taking care of him/her but has the potential of affecting all the nurses in the ward at the time, then there is shared grief over the experience. From this account as well, the participant suggests that when a patient death occurs, the nurse goes through a process of questioning, or analysis of what led to the death. This inquiry touches on the competence of the nurse and can have a spillover effect on the relationship of the nurse with his/her family at home. The quotation ends with the participant expressing the potential of the patient death experience affecting the physical health of the nurse as it can lead to a loss of appetite. Motivational impact of experience; It is important to note that the experience of patient death from the perspective of the participants is not all-negative. This was the case for 3 of the participants. The responses indicate that the experience can make the nurses reflect on the experience and put in more effort to ensure that they do their best for the next patient they are attending to. Because the loss of lives on the ward is disturbing, nurses, therefore, put in the effort to handle the next case even better to save lives. Also, to avoid questioning their competence after the loss of patients, nurses endeavor to “check all the boxes” with regards to what nursing care must be provided for the patient. “It taught me to always be on my toes to do my best so that in case a patient passes on, I don’t blame myself that much. Because I will go through my checklist to ensure that I have done everything I need to do for the patient at that particular time and the patient is gone. So even though I will feel bad or guilty, it would not get to that extent, you see” (Participant 4 F26:6) In this quote, the participant narrates how the patient death experience has served as a basis for which work must be done efficiently. He explains that if he is convinced that he has put in his best efforts and cared for the client in the best possible way, the impact of the demise of that patient will not be as severe as in a situation where he didn’t put in his best. Mortality awareness and personal introspection; The experience of patient death also represents an opportunity for introspection for the nurses. When a death occurs on the ward, the responses of some of the participants show that they are reminded of their own mortality as well as the need to reflect on decisions in life. “Hm when these things happen, it makes you think a lot. You see the sickle cell issue. So it got me thinking. If you are choosing a marriage partner, you don’t have to think of love alone. If the two of you are not compatible, you must advise yourself before you marry and go and give birth to children who will be suffering. And I also pray about it” (Participant 9 F22:1) Here, the participant underscores the potential of a patient death experience to ponder over one’s own life choices and the effects that the choices will have on others in the future. 4.3.3 Coping strategies Coping strategies refer to the various techniques adopted by the nurses individually and also as a group to manage the psychological and emotional impact of the patient death experience. From this, some subthemes emerge, namely informal ward discussions, inquiry into the cause of death, a spiritual experience, and psychological dependence. Informal ward discussions; Since they work in the same environment and therefore share the experience of patient death, the nurses rely on having discussions with each other in order to deal with it. The nurses shared their experiences with colleagues in order to lighten the psychological weight imposed on them by the experience. “And situations like that are difficult. We just talk about it as colleagues, try to discuss what happened from the beginning and also just to get it off your mind a bit. It helps oh. Not completely, but it helps” (Participant 12; F32:4) This participant emphasizes on the fact that after the experience of patient death, the nurses in the ICU adopt the discussion of the experience and how they felt when it happened, with the aim of avoiding a rumination over the event even as they continued with their work. She states then that the strategy helps to some extent to cope with the loss. Inquiry into cause of death; another coping mechanism adopted by nurses on the ward as found by this study is making attempts to determine if anything went wrong with regards to the practice of nursing, causing the death. “Yes, we do. So we take a patient folder and discuss. I mean how it happened and going forward, what we are going to do to come out of that trauma. I mean we motivate ourselves and pray among ourselves. There are times in a month, you have a lot of deaths. When you open the book, you see that that month there are so many names written in red and you know we work with national service and rotation nurses, and you know these ladies. Sometimes they fear.” (Participant 8 M31:6) This participant explains that in order to cope with the patient death experiences, they discuss among themselves how the death happened and their reactions. Then the nurses would attempt to prepare psychologically for similar happenings in the future. She adds that they express the shared grief, motivate each other and say prayers. A spiritual experience; The results of the study also indicated that when confronted with patient death, the participants gleaned insights from their relationship with God or a Higher Being as well as belief systems in order to cope. It must be noted that while some of the participants prayed after the loss of a patient and during the performance of the last offices, others also saw patient death in the ICU as the patient’s own way of transitioning from life. Again, participants reported that the knowledge and acceptance of their own mortality was a resource that was adopted in the coping process. “I just see it as it is just a transition, and if it is really meant for her to survive, she will survive, but when the unfortunate thing happens, I just see it as the patient’s way of saying goodbye” (Participant 3 F28:3) The participant in the quotation above views the patient death experience as one that is required for each individual and an avenue where humans transit to the afterlife. He asserts that this view of the inevitability of death in spite of all effort is what helps him to cope with the experience. “I also try to have a way of living my normal life, not like going to the club but at least doing something that will keep me happy. The last thing is that it makes my Christian life become more serious, I mean death is real, you know” (Participant 4 F26:6) Here, the participant also opines that the patient death experiences serve as a reminder that death is inevitable for all humans, and he actualizes this belief in living the best way possible and also striving to be at peace with God. Psychological dependence; One participant indicated that some activities such as an analysis of what led to the loss of the patient, prayer, and the use of alcohol are effective in coping with the experience of patient death. “Yes, I take some time off to analyze it. you know there are some cases that are avoidable, and you think about it, how did this happen, what did I do wrong, what was I supposed to do that I didn’t do? So I analyze it and when I am doing last offices I pray for the patients. And at that point if you know how to drink, you drink something (alcohol). After drinking you become cool and then you move on” (Participant 8 M31:9) The participant in the quotation above adopts a strategy of analyzing patient death experiences of cases which he considers could have been avoided and questions his own handling of the patient and professional competence. By way of coping as well the participant indicated that he makes a habit of praying for the patients while carrying out last offices. In conclusion, he adds that psychological dependence on some alcohol can also help to take one’s attention from the experiences. From the above, it is seen that the participants adopted both problem and emotion-focused soping styles. The ward discussions and inquiries into what had happened focused on the problem, that is the death of a patient, as the nurses tried to make sense of what had happened and also draw lessons from it. On the other hand, the view of the patient death experience as a spiritual experience that refered them to their own mortality and relationship with God was as a result of their emotional reaction to it. Another instance of emotion-focused coping can be seen where the participant indicates that he drinks to deal with the emotional impact of the experience. 4.3.4 Administrative structures. Administrative structures here encompass the various systems put in place by hospital and nursing administration targeted at helping the nurses manage the emotional and psychological impacts of the experience of patient death. The quotations below highlight the responses of the participants in the study. Under this, the theme random clinical psychological sessions emerge. Random clinical psychology sessions; Participants indicated that these were provided in only a few cases where the patient death experience left the nurses on the ward traumatized. “There was one time that we even talked about that thing, because one of the staff said they go through a lot in the ICU and would even wish from time to time we would have a clinical psychologist come around. And they are in the hospital so they can see them, and the clinical psychologist said he can see them. I think when they also come, not like we going like we have a problem per se, it will help a lot, yes. It happened because, I even called that psychologist, it was the COVID time and our initial exposure to COVID, we had a patient and the patient died of COVID, and we had already worked on him, so most of the staff were afraid. So I had to go and call the psychologist and some of the hospital managers to come and talk to the staff because it was not easy, you know” (Participant 4 F26:6) This participant recollects an instance in which a clinical psychologist was called upon to help nurses in the ward upon their request because they were in a state of fear after a patient they had treated had passed away. The patient was earlier diagnosed of having COVID. The nurses on the ward had suggested that the sessions with the therapist be continuous as the need for help was enormous. However, the participant emphasized the fact that they wanted the psychological interventions in their ward, and not at the psychology unit in order to avoid. He then suggests that misconceptions about their mental health. Over here, it is important to note that the nurses preferred to have the sessions with the clinical psychologist in their ward so as to have sessions as a group instead of individually. 4.3.5 Recovery Under this theme, the participants of the study shared how their experiences of recovery from the phenomenon of patient death. A majority of participants who indicated that they were no longer affected by the phenomenon attributed this recovery to time and opined that the more time one spent in the ward or the more experiences of patient death an individual has, the better they will be at dealing with the psychological impact of it. Hence the subtheme psychological adjustment over time. Psychological adjustment over time; Even though some of them indicated that the experience no longer worried them, they also expressed the fact that they believed that the experience had significantly changed their personality, specifically with regards to the showing of empathy to critically ill and dying patients. Other participants also indicated that since there was the need for work to continue, the nurse must endeavour to suppress the felt emotions and carry on with the work. “When it happens, for me it is painful. Even though I have seen it many times, I still get emotional anytime it happens and sometimes I have to stop and take a minute to calm down before I can continue. But with time I have tried not to be thinking about it much. I won’t say I’m used to it now. But I try, you see. If you say you will go and cry, who will continue the work?” (Participant 11 F25:8) The participant here asserts that every experience of patient death has can result in feelings of sadness, in spite of the number of experiences one may have had. From her recollections, the participant indicates that the psychological and emotional impact of the experience is such that after such an experience, there is a need for her to take a short break to regain her composure before continuing with work. She reiterates the idea of disenfranchised grief, by indicating that there is no one to continue the work if she stops to cry. Hence, a maintenance of composure represents a masking of ones internally felt emotions so as to carry on with work. 4.3.6 Capacity to manage experience Finally, this theme explains the views of the participants with regards to the adequacy of their training with regards to dealing with their own experience of patient loss. Themes that emerged here are focus of training and personal adjustment to experience. Focus of training; The participants all indicated that the component of their training that dealt with patient death focused on the experiences of relatives of deceased patients and not on the nurse. They mentioned that the grieving process was explained to them. This was done as part of the performance of last offices. “No there was nothing like that during my time. We were taught about what the relatives go through rather. It is called DABDA. That is what I know relatives go through. But for the nurses or the staff, no” (Participant 4 F26:6) In the above quotation, the participant indicates that the focus of her nursing training course with regards to patient death was on the grief processes that relatives of patients after the patients have passed away. She recalled the stages of grief as propounded by Kubler-Ross namely, the stages of denial, anger, bargaining, depression and acceptance. In her conclusion, she suggests that there was no part of the training that focused on the nurses with regards to the phenomenon. As a result of the fact that the training did not include how the nurses would deal with their own experiences of patient death, the nurses have to develop the ability to handle the experience themselves over time. Personal adjustment to experience; from the findings, the participants indicated that there is a need for an individual adjustment to the patient death experience in order to be able to work effectively with the experience of patient death. “Hm, for the nursing training, they won’t teach you oh. The training did not cover things like that. You have to face it on your own. Because of that, in the beginning when you start working, it is very difficult. I can even say that plenty people who finish nursing school, get posted but stop along the way is because of this. Imagine having 2 people die on your first day on the ward, and you are supposed to just continue working like that. Hmm, it’s hard. But you are not trained for it like that” (Participant 10 F34:11) The quotation depicts a need to learn on the job and adapt to the fact that patient death experiences are a part of the job. The participant begins with an expression of frustration over the fact that education on the patient death experience and how it affects the nurse was not a part of the nursing training curriculum but goes ahead to stress on the need for one to learn to adapt to the experience on the job, a process she describes as difficult. This is due to the fact that it would take time and several experiences for one to be able to continue working after the experience. She attributes a rate of turnover decisions on the part of nurses to a difficulty in managing the effects of the experience of patient death. Summary In summary, the results indicated that ICU nurses experience some level of psychological distress when working with dying patients and also dealing with the death of patients. They do not have the requisite capacity in dealing with the distress because their training with regards to patient death focused more on the experiences of relatives of the dying patient. It is important to note that in spite of the significant distress reported by participants as a result of the patient death experience, it also holds some constructive implication. First of all, the nurses are driven to put in much effort the successful management of the subsequent patients. They report also that the experience results in a consciousness of their own mortality and thus a strengthening of their relationship with God. With regards to coping, the participants adopt both formal and informal discussions in order to make sense of what happened. It was also found that some of the participants employ unhealthy coping mechanisms such as alcohol use in order to manage the impact of the experience. The participants also indicated that they receive some form of psychological interventions randomly. These, the participants indicated were in cases where they were all observed to be traumatized after a patient death experience. Finally, the nature of their training regarding patient death was explored. It focused on the grief process of relatives of the patient and did not entail the impact the experience had on nurses. As a result of this, the participants indicated that they were not in a position to effectively handle the experience and had to manage to come up with their own systems of coping over time. CHAPTER 5 DISCUSSION 5.1 Introduction The study was conducted to explore the lived experiences of intensive care unit (ICU) nurses in selected hospitals in Ghana with regards to patient death, coping and recovery. The study also sought to explore coping and recovery from the experience of patient death. This chapter will discuss these findings in some detail with reference to similar literature. The chapter will then conclude with the provision of possible implications of the findings, limitations of the study and a suggestion of recommendations for future studies. In the study, it was found that the participants’ memories of experiences of patient death were influenced by their first or initial experiences, patient’s conditions that influenced grief and their emotional reactions to the experience. The study also revealed some psychological impacts of the experience on the participants. These included the tendency to question one’s competence, emotional numbness as a result of recurring experiences, motivational impact of experience and the awareness of one’s mortality (personal introspection). Some coping strategies adopted by participants included informal ward discussions, inquiry into cause of deaths, a spiritual experience and psychological dependence. It was also found that administratively, random clinical psychological sessions were made available to the nurses when this was requested for. With regards to recovery from the psychological effects of the experience participants indicated that they had to make psychological adjustments over time. Finally, the nurses’ capacity to manage the experience hinged on the focus of their training as well as their adjustments to the experience. 5.2 Nurses' memory of the experience of patient death Data gathered from the study indicate that the experience of patient death is traumatic and elicits intense emotional and psychological reactions among the nurses. This was similar to the findings of other studies (Khalaf et al., 2017; Rickreson et al., 2005). From insights gleaned from participants in the study, the first experience of patient death is a major stressor and an experience that stays with them throughout their practice. In a related study, Parry (2011) found that the first experience of patient death can be stressful but also an influential experience, that had the potential of determining how the individual will handle such situations throughout their career. As a result, there is a need for adequate support to be provided during this stage (Kent, Anderson & Owens, 2012). The study also found that the condition of the patient also could influence the grief reactions of nurses. A key component of the nurses’ recollection of the patient death experience is the fact that the condition of the patient, with regards to age and similarities with the nurse. With that, the emotional reactions to the death of patients are more intense when they identify with the patient (Zyga et al. 2011). The emotional reactions to the experience of patient death ranged from fear, sadness, and anger. 5.3 Psychological impact of patient death experience The patient death experi