Development and Evaluation of a Self-Reflection Program for Intensive Care Unit Nurses Who Have Experienced the Death of Pediatric Patients

Hyun-Ju Kang; Kyung-Sook Bang

doi:10.4040/jkan.2017.47.3.392

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Kang and Bang: Development and Evaluation of a Self-Reflection Program for Intensive Care Unit Nurses Who Have Experienced the Death of Pediatric Patients

Original Article

J Korean Acad Nurs 2017;47(3):392-405.

Published online: 15 January 2017

DOI: https://doi.org/10.4040/jkan.2017.47.3.392

Development and Evaluation of a Self-Reflection Program for Intensive Care Unit Nurses Who Have Experienced the Death of Pediatric Patients

Hyun-Ju Kang¹, Kyung-Sook Bang^2,

¹Department of Nursing, Kangwon National University, Chuncheon

²College of Nursing · The Research Institute of Nursing Science, Seoul National University, Seoul, Korea

Address reprint requests to : Bang, Kyung-Sook College of Nursing · Seoul National University, 103 Daehak-ro, Jongno-gu, Seoul 03080, Korea Tel: +82-2-740-8819 Fax: +82-2-765-4103 E-mail: ksbang@snu.ac.kr

Received 8 January 2017 Revised 22 May 2017 Accepted 22 May 2017

This is an Open Access article distributed under the terms of the Creative Commons Attribution NoDerivs License. (http://creativecommons.org/licenses/by-nd/4.0) If the original work is properly cited and retained without any modification or reproduction, it can be used and re-distributed in any format and medium.

Abstract

Purpose

This study aims to develop a self-reflection program for nurses who have experienced the death of pediatric patients in the intensive care unit and to evaluate its effectiveness.

Methods

The self-reflection program was developed by means of the following four steps: establishment of the goal through investigation of an initial request, drawing up the program, preliminary research, and implementation and improvement of the program. The study employed a methodological triangulation to evaluate the effectiveness of the program. Participants were 38 nurses who had experienced the death of pediatric patients (experimental group=15, control group=23); they were recruited using convenience sampling. The self-reflection program was provided over 6 weeks (6 sessions). Data were collected from April to August, 2014 and analyzed using t-tests and content analysis.

Results

The quantitative results showed that changes in personal growth (t=-6.33, p<.001) and burnout scores (z=-2.76, p=.005) were better in the experimental group compared to the control group. The qualitative results exhibited two themes, namely “personal growth” and “professional growth”, and ten sub-themes.

Conclusion

The self-reflection program developed by this study was effective in helping nurses who had experienced the death of pediatric patients to achieve personal growth through self-reflection, and it was confirmed that the program can be applied in a realistic clinical nursing setting. Furthermore, it can be recommended as an intervention program for clinical nurses.

Keywords: Death, Intensive care unit, Nurses, Program development

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Table 1.

Research Design for Quantitative Study

Group	Pretest	Treatment	Posttest	Pretest	Treatment	Posttest
Control	C₁	No (6weeks)	C₂
Experimental				E₁	Self-reflection program (6weeks)	E₂

C1, E1=General characteristics, personal growth, compassion satisfaction, compassion fatigue, burnout; C2, E2:=Personal growth, compassion satisfaction, compassion fatigue, burnout.

Table 2.

Self-Reflection Program for Intensive Care Unit Nurses Who Have Experienced the Death of Pediatric Patients

Step	Session (Time)	Theme	Objectives	Contents
Introduction	1^st (90min)	What is my emotional	Understand the objective and steps	General overview of the program,
		expression style?	of the program.	contents of each session and
		: Confirmation of emotional	Facilitate understanding between the	participation
		control style profiles	moderator and participants, and	Introduction of oneself by a nick-
			among participants, and create	name
			intimacy.	Confirmation of the final result for
			Understand one’s own emotional	emotional expression style
			expression style.
Development	2^nd (120min)	The one child who remains	Talk about the experience of the	Debriefing about one’s experience
		in my memory	death of pediatric patients in a safe	of the death of pediatric patient
		: Sharing experiences of	and comfortable environment to	Verbalization of one’s emotion
		caring for dying pediatric	achieve emotional resolution.	through debriefing
		patients		Empathy and support among the
				participants
	3^rd (90min)	Into the basket of loss	Reflect on personal loss to look	Verbalization of loss that holds
		: Sharing my experience of	back on one’s life and understand	personal meaning
		loss	oneself.	Use of the empathy card to encou-
			Use the empathy card to encourage	rage the participants to empathize
			the participants to empathize.	Writing a short note on one’s
				personal experience of loss and
				placing it in the basket of loss
	4^th (90min)	Parting well	Restructure the meaning of the	Restructuring the meaning of the
		: Finding my special parting	death of pediatric patients to clearly	death of pediatric patients through
		ceremony	understand the remaining emotions	letter writing
			and hope.	Creating one’s own parting cere-
			Acquire specific strategies to handle	mony through group discussion
			personal emotions regarding the
			death of pediatric patients through
			group activities among participants.
	5^th (90min)	Understanding the parents	Understand the bereaved parents and	Reading books about bereaved
		: Finding an effective	identify effective communication	parents and sharing emotions
		strategy for	strategies as a bereaved nurse.	Share the experience of meeting
		communication with the		bereaved parents
		parents		Writing a condolence card to bere-
				aved parents
Conclusion	6^th (90min)	I am a pediatric nurse	Plan and act on self-care strategies.	Writing and sharing a specific mini
		: Establishing a self-care	Confirm the value of caring as a	holiday plan
		strategy	pediatric nurse at the intensive care	Reflecting on one’s life as a nurse
			unit.	and creating a new resolution
			Conclude the program.	Providing feedback to each other

Table 3.

Homogeneity Tests between Experimental and Control Groups at Baseline (N=38)

Characteristics		Exp. (n=15)	Cont. (n=23)	c² or t or z	p
			n (%) or M±SD
Age (yr)		27.87±1.88	26.61±2.27	-1.78	.083
Marital status^†	Unmarried	12 (80.0)	20 (87.0)	0.33	.663
	Married	3 (20.0)	3 (13.0)
Offspring^†	Yes	2 (13.3)	0 (0.0)	3.24	.149
	No	13 (86.7)	23 (100.0)
Education level^†	3 year college	3 (20.0)	4 (17.4)	0.11	>.999
	Bachelor	9 (60.0)	15 (65.2)
	Master	3 (20.0)	4 (17.4)
Religion	Yes	9 (60.0)	11 (47.8)	0.54	.522
	No	6 (40.0)	12 (52.2)
Coresidence with family^†	Yes	11 (73.3)	12 (52.2)	1.70	.310
	No	4 (26.7)	11 (47.8)
Personality	A-type	9 (60.0)	18 (78.3)	1.47	.285
	B-type	6 (40.0)	5 (21.7)
Current working unit	NICU	10 (66.7)	12 (52.2)	0.78	.506
	PICU	5 (33.3)	11 (47.8)
Clinical career, hospital (yr)		4.70±2.02	3.77±1.91	-1.43	.162
Clinical career, NICU or PICU (yr)		3.50±1.90	3.60±1.67	0.17	.863
Number of pediatric patient’s deaths encountered during their career		9.73±11.74	13.00±13.31	0.77	.444
Number of pediatric patient’s deaths encountered during last year		4.07±2.96	5.09±3.52	0.93	.359
Most memorable pediatric patient’s death	<6 month	9 (60.0)	12 (52.2)	0.23	.744
	≥6 month	6 (40.0)	11 (47.8)
Death of significant others	Have	5 (33.3)	7 (30.4)	0.04	>.999
	None	10 (66.7)	16 (69.6)
Education related to terminal or hospice care†	Yes	2 (13.3)	5 (21.7)	0.43	.681
	No	13 (86.7)	18 (78.3)
Personal growth		38.80±11.23	41.00±12.98	0.54	.594
Compassion satisfaction		32.80±3.59	33.96±4.41	0.85	.402
Compassion fatigue		32.73±4.20	31.30±4.48	-0.99	.331
Burnout*		30.87±4.67	29.04±3.27	-0.65	.535

NICU=Neonatal Intensive Care Unit; PICU=Pediatric Intensive Care Unit; Exp.=Experimental group; Cont.=Control group.

^†Fisher’s exact test; *Mann-Whitney U test.

Table 4.

Comparison of Personal Growth, Compassion Satisfaction, Compassion Fatigue, and Burnout between Experimental and Control Groups (N=38)

Variable	Time	Exp. (n=15)	Cont. (n=23)	t or z	p
		M±SD
Personal	Pre	38.80±11.23	41.00±12.98
growth	Post	53.27±10.46	40.48±10.42
	Post-Pre	14.47±6.87	-0.52±7.30	-6.33	<.001
Compassion	Pre	32.80±3.59	33.96±4.41
satisfaction	Post	34.73±3.58	34.52±3.85
	Post-Pre	1.93±4.17	0.57±2.50	-1.27	.213
Compassion	Pre	32.73±4.20	31.30±4.48
fatigue	Post	31.87±5.41	30.17±3.66
	Post-Pre	-0.87±3.27	-1.13±3.97	-0.21	.832
Burnout	Pre	30.87±4.67	29.04±3.27
	Post	27.87±3.20	29.09±3.66
	Post-Pre*	-3.00±3.27	0.04±2.23	-2.76	.005

Exp.=Experimental group; Cont.=Control group.

^*Mann-Whitneey U test.

Table 5.

Qualitative Themes and Sub-themes Emerging from Focus Group Interview

Themes	Sub-themes
1. Personal growth	1) Self-understanding through facing one’s
	inner self
	2) Emotional expression and resolution
	through self-exposure
	3) Restored comfort and confidence through
	peer support
	4) Having the opportunity for willingness to
	practice self-care
	5) Increase in spiritual interest
2. Professional	1) Increased capacity to cope with pediatric
growth	patients’ death
	2) Increased awareness of the importance of
	the child
	3) Improved empathy for the family of pediatric
	patients
	4) Looking for the value of professional nursing
	roles and the motivational power of my job
	5) Expecting continued support programs for
	nurses

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