Our sample consisted of fifteen clinical nurses recruited from two large-scale, tertiary comprehensive public hospitals in Shandong province between June and August of 2020. All participants had experience in coping with patient death in the hospitals at which they were employed within the prior six months. Only 1 of the 15 clinical nurses had participated in hospice care training, and none of the nurses had any experience in death education before the interview. Their time working on clinical nurses’ respective wards before the interviews ranged from 2 to 20 years. The duration of interview ranged from 30 to 90 minutes (mean duration: 60 min). Table S1 summarizes the characteristics of the participants.
Three thematic categories emerged from the rich interview data provided by 15 clinical nurses (Table S2): Negative emotions from contextual challenges; The awareness of mortality on its own; and Coping style.
The first subtheme within the first thematic category identified was "grief over deaths of younger persons." Thirteen of the 15 participants felt despair when coping with deaths of infants, children, and young and middle-aged patients. The end of a younger person’s life felt more distressing and stressful for clinical nurses than the death of an older person. They associated the deceased with their own children or loved ones, and felt responsible for their deaths.
N1: “A little boy patient in our department passed away. So, all the people in the whole department were in a very low mood for an afternoon.”
N6: “I see the dying boy, and I think of my son......He [dying boy] makes me feel very sorrowful.”
N8: “We feel that the death of the elderly is a natural part of our life. But the death [accidental death] of young people made me feel very sympathetic; it’s difficult for me to witness.”
We named the second subtheme "pity for deaths without family." Nurses' sadness and regret often emerged from the surrounding context of dying patients and the state of their death. Nurses feel that dying people need a caring environment, and the company of families can allow the patient to die peacefully and achieve a good death. Dying unaccompanied was associated with feelings of sorrow and regret.
N9: “Some patients' family members prepared shrouds for the patient in advance and accompanied the patient until the patient passed away... But when another patient died, his son was abroad and couldn't come back to see him one last time. We sincerely regret it.”
N10: “I was sorting through the patient's belongings when I saw the picture of his kid in his wallet, and I felt so sorry. He [the patient] probably misses his son a lot.”
N15: “How heart breaking it is that the man had only a care worker with him at the end of his life.”
The third subtheme identified was "dread related to coping with patient death on night duty." Participants were afraid to cope with death on night shifts. Their fear was related to the heavier workload due to increased hospitalizations and emergency department visits. In large general hospitals, the number of night nurses is much smaller than the number of day nurses. At night, in addition to routine treatment for hospitalized patients, nurses also had to handle new patients’ treatments. Insufficient nursing staff made coping with patient death during the night shift much more difficult.
N2: “Everyone's energy is limited, but every patient needs attention and needs to be taken care of. I am very scared that I would have to cope with patient death at night. I'm feeling overwhelmed and worried.”
N3: “Even though I've been working for years, I still find it difficult, stressful, and scary to cope with the patient's death on the night shift.”
N14: “Our department did not handle this kind of case [planned deaths in hospital per patient/family request] before, but now we are not allowed to refuse to admit these dying patients. The number of personnel on duty varies between day shifts and night shifts. Due to the surge of [dying] patients, I can be exhausted sometimes when I work nights.”
The second thematic category, "the awareness of mortality on its own," consisted of two clusters relating to "death means that everything stops being" and "good living." None of the nurses had previous experience with education regarding death of patients. Their understanding of death was simply that the patient no longer existed, and death is nothingness. On the other hand, most clinical nurses recognized that death is an unavoidable part of life and grasped the finality of death.
N7: “After he died, nothing he ever owned mattered. It doesn’t have much to do with his life.”
N12: “After he [patient] dies, there’s nothing left. Deaths from this disease seem inevitable. We had long expected this outcome [death] of his illness.”
For most of the clinical nurses, who were mothers with children, the lessons learned from coping with patient death were living peacefully and living well. Despite most of them replying that it is impractical for them to explore the meaning of life, processing patient death may influence nurses to prioritize good living in daily life.
N6: “It [coping with death] reminds me to live well. I have my children, I can’t get sick, I can’t die. I can’t take care of my son if something happens to me.”
N8: “Death is an unavoidable part of life. I focus on the present and learn to live here and now, especially for my children.”
The third thematic category, "coping style," consisted of three subthemes: "focusing on treating dying patients, recording the signs and symptoms, and responding to changes in the patient’s condition;" "avoiding talking about death due to the grief associated with dying and death;" and "seeking help from colleagues." The overwhelming majority of nurses believed that providing direct care was the best way to meet the preferences of patients and their families in the hospital, unless their family instructed them to give up on curative treatment. Participants reported closely observing patients' vital signs and symptoms, monitoring changes in their conditions, and taking proper care of patients (e.g., providing emergency nursing and palliative care). Therefore, clinical nurses offered multiple life support techniques, including medications, injections, and other treatments intended to cure. However, participants felt that their condition could result in severe consequences, such as rapid deterioration or death, if not addressed promptly.
N2: “In the clinical setting, we pay attention to assessing the dying patients’ physical conditions, and appropriate actions should be taken immediately if any abnormalities in vital signs appear.”
N4: “They [patients and their families] seem to prefer that we provide her [patient] with medication and injections because that means there is still hope for a cure. I had proficient clinical skills, and I could take good care of patients.”
N5: “Every month, we need to be trained in first aid and other nursing skills. We [doctor and the nurse] coordinated well in saving the patient.”
N11: “We emphasized the need for their [patients and their families] demand for treatment and integrated aggressive treatment into their end-of-life care.”
Clinical nurses were often unwilling to talk about death with others. Moreover, most participants noted that the underlying cause of being hesitant to talk about death was the grief related to dying and death, rather than feeling like death is mysterious. Only one clinical nurse responded that death brings bad luck, a belief that seemed to have been deeply affected by her superstitious grandmother. Nurses actively resist being engulfed by grief and sorrow, because death means that everything no longer exists.
N7: “I don’t like to talk about death, because I don’t want to immerse myself in heavy topics.”
N9: “When a patient dies, we don't go back into the patient's room that day... I fear that I’d become sad if we talked in depth about dying and death.”
N13: “I was reluctant to engross myself in talking about death with my kid. Little or no attention seems to have been given to talking in-depth about death because of the grave sadness.”
Clinical nurses often sought help from colleagues in situations such as resuscitating actively dying patients, delivering bad news to patients, showing more care in treating dying patients, or deciding when it is and isn’t appropriate for them to communicate directly with patients' family members.
N10: “When we encounter difficulties in communicating with dying patients, we usually consult senior nurses... If I take the initiative to comfort the patient, it's like deliberately reminding the patient that you're going to die, you’re going to die. But if I don't comfort the patient, we seem too indifferent. So, I don't know how to communicate with patients or their families.”
N13: “Whether or not a patient is an organ donor is also essential, and I'd like to be able to participate in talks. I usually ask the attending physician for help because many things need to be conveyed by the doctor, and there will be better results [compared to information being conveyed by nurses].”