Original Article

Exploring the Intensive Care Nurses’ Experience after Neonatal Deaths: A Hermeneutic Phenomenological Study

Introduction

Bereavement and grief are two common emotions caused by losing someone valuable in your life.¹ Grief is the internal part of the loss. Nurses may experience this personally, or they may be the support system for patients and their families going through grief and loss.² Bereavement is conceptualized as a dual process involving the management of two primary stressors: the “process of loss” and the “process of restitution.” An individual’s mental health is determined by their capacity to oscillate adaptively between these two processes. However, nurses caring for families experiencing neonatal death and loss may also experience bereavement, and, therefore, it is important to explore the experience of grief in this context.³

Being in a state of grief is a profound human experience. Bereavement is a common human emotion that holds significant importance in the field of nursing.¹ In many situations, nurses must care for families going through the emotional distress, and bereavement of neonatal death. However, there is a risk that this suffering may also affect the nurses’ well-being, and this often goes unrecognized and undiscussed.⁴

Among parents, grief often begins with the anticipation of death, which may be influenced by the mother’s medical history, presenting symptoms, or intuitive premonitions. Participation in mourning rituals and the opportunity to acknowledge the infant’s identity, even in death, can facilitate the grieving process.^5,6 However, this complex and emotionally charged context presents significant challenges for nurses, who must navigate both the parents’ bereavement and their own professional and emotional responses.⁷

The neonatal intensive care unit (NICU) is a space where nurses, doctors and other health professionals must face the care and attention of patients in critical health and support families. However, the death of a child is also an intense and painful emotional experience for the NICU nurses,^5,8,9 which when repeated, can have a negative impact on the mental health of the professional.^8,10,11

Nurses cope with the parents’ loss through caregiving, and personally, in various ways, making sense of it, conditioned by personal and professional determinants. They unravel the grief of loss by searching for experience, expressing it, focusing on it, and, simultaneously, detaching themselves from it.¹²

Although some research has described responses, attitudes, and perceptions to show that healthcare professionals experience a variety of difficult emotions,^5,13,14 research delving into the experience of neonatal death for critical care nurses is lacking.^13,15 Hence this study helps nurses working in neonatal critical care units to have a better understanding of grief and support skills. When properly addressed, grief can help nurses process their pain, further facilitating growth in professional identities.²

Sadness, anger, frustration, and helplessness are some of the feelings that can surface in nurses at a neonatal death.⁷ They also usually find it difficult to witness the parents’ pain and suffering.¹⁶ Even though, during a neonatal death, nurses want to feel helpful and relieve it.¹⁷ In other cases, nurses hide their emotions and reactions from parents and peers as a mechanism to avoid exposing their feelings.¹⁸ Clinicians also need adequate emotional and practical support from their organizations.¹⁹

Qualitative studies have a unique ability to help researchers achieve a better understanding of NICU nurses’ experiences after neonatal death and can explain and describe their emotions, views, and points of view based on their professional, cultural and social backgrounds. Thus, the aim of this study is to explore the experiences of nurses’ grief after neonatal death in the NICU.

Materials and Methods

This study was a qualitative research performed with a hermeneutic phenomenology approach.²⁰ It is focused on narrative interpretation, to explore the experiences of grief by nursing professionals when faced with the death of hospitalized neonates in two NICUs.

All the NICU nurses met the inclusion criteria, which included rotating schedules, experience in working as a NICU nurse for at least two years, to have directly lived the phenomenon of neonatal death, and to authorize their participation following an informed consent. The exclusion criterion included consanguinity relationship with patients or nurses who had a history of their relatives dying in this ward.

The sampling method was snowball and purposive sampling taking the maximum variation possible into account to obtain different opinions on the phenomenon from the best informants. Data saturation was reached after 11 interviews (no re-interviews) and no new information emerged. The sociodemographic characteristics of the nurses (such as age, gender, credentials) were collected using a self-completed survey provided by the authors (Table 1).

Data was collected through semi-structured interviews conducted in face-to-face meetings between the researcher and participants, directed towards the expression of their grief experiences and what the death of a newborn meant. The NICUs were located in two private teaching hospitals, each with a capacity of 10 beds. The data was collected in the hospitals settings and the interviews were conducted in a hospital classroom with an appropriate environment, without interruptions, outside of work hours. Data were collected from June to December 2022. The nurses were asked to describe their experience, following the next questions as interview guidelines:

Have you witnessed neonatal deaths on your shifts?

What was that experience like?

What were your feelings when faced with neonatal death?

What factors influenced your reaction?

How do you consider that you handle grief and bereavement in the face of neonatal death?

Each interview lasted between 45 and 90 min, with an average of 60 minutes. The interviews were recorded using a voice recorder and conducted by a female nurse trained in qualitative research (C.V.) with an MSc in nursing, and more than 15 years of experience as a neonatal intensive care nurse. The sociodemographic data of participants was gathered by a self-completed form.

To facilitate this analysis, the transcription of interviews and observations was carried out at the same time. Each interview was coded, and through a systematic process of line-by-line, sentence-by-sentence, and paragraph-by-paragraph examination, units of meaning were identified. This approach enabled the recognition of key phrases and words that encapsulated the central ideas within these units, thereby allowing for the organization and conceptual structuring of the data. This, in turn, facilitated the construction of the experiences that emerged from the analysis of the narratives. These findings led to the construction of the following interpretative framework.

The interpretative framework encompassed the experiences that are the result of the concepts or signifiers; the concepts, the keywords of the central ideas and the experiences phrases, ideas that allow for the interpretation of what was expressed by each nurse.

Data were analyzed using content and thematic analyses method as follows: Data transcription with details, understanding the depth of meanings, extracting important phrases, placing concepts in categories and clusters and then forming themes, integrating study results to describe the phenomenon, stating the essential structure of the phenomenon, and finally validating the findings.²⁰

This interview was reviewed by another nurse (M.C.) for comprehension and language. These interviews were transcribed verbatim. The interviews were then coded to avoid participant identifications and to maintain fidelity. Subsequently, a line-by-line, sentence-by-sentence, and paragraph-by-paragraph analysis was performed, from which the units of meaning were obtained, understood as those stories that initially support the concepts and give rise to the experiences. Subsequently, a summary of the data was made through the grouping of similar “concepts or signifiers” codes that facilitated the construction, description, and analysis of the experiences. A detailed analysis of each interview led to confronting ideas, and to considering different forms of classification, to establish differences and similarities between their narratives and, thus, structure the experiences. The design of a matrix whose content allowed for the exploration of the subjective world of the participating nurse and the search for the meaning of her expressions was designed; in the establishment of a dialogue of knowledge (bibliography, participants, and researcher). This allowed for the construction of the interpretative framework.²⁰

The credibility of the research was ensured by obtaining true and real results from the recorded interviews, which were transcribed, verbatim, to preserve the purity of data and expressions.²¹ The first author (C.V.) coded the interviews, and the second author (M.C.) recoded. The applicability of the study and the possibility of extending the results to other populations with similar characteristics were considered. To improve transferability, in-depth interviews were conducted using open-ended questions, and participants with different characteristics were selected by purposive sampling to increase data diversity and abundance. To guarantee dependability, the data analysis process was recorded and documented in detail and reviewed by experts for its appropriateness of classification. To assure confirmability, the researchers permanently checked and documented the transformation and classification process for the raw data. The present study was undertaken following the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.

Results

A sample of 11 professional nurses, aged 25-50 years old and female, from 2 and 20 years of experience in NICUs, was recruited. Our analysis produced five main themes and their supporting narratives, as follows (Table 1).

First Main Theme: Emotions of Nursing Professionals Caused by a Neonatal Death

The theme “emotions caused by neonatal death” presents the importance of the experiences attributed to the specific situations that give rise to emotions. For the nursing professionals working in the NICUs of the two institutions, death can be especially painful, charged with emotions of pain, uneasiness, frustration, sadness, guilt, relief, helplessness, and loss (Table 2).

The uniqueness of neonatal death lies in how nurses perceive and interpret the experience. Their assessments are influenced not only by the external circumstances but also by their internal emotional responses. Nurses’ accounts revealed profound sadness associated with grief, shaped by the interpersonal relationships formed during care:

“I was told that they asked why he died, and seeing how broken his parents were, I was very sad, I felt loneliness, sadness in the air” (Participant #5).

Second Main Theme: Behaviors and Reactions from Nurses after a Neonatal Death

Nursing professionals face neonatal deaths with reactions or behaviors that are especially based on lived experiences and their formal and non-formal educational backgrounds.

The interview questions allowed for the identification of several behaviors and reactions such as harshness (insensitivity), questions, partings, spirituality and religiosity, and bravery. This line of thinking led to experiences of hardness:

“One gets used to this, to so much neonatal death, one gets used to it, one becomes harder, sensitivity is lost” (Participant #4).

The Questions reaction is reflected:

“If a patient dies, you always ask yourself: why did she die?” (Participant #3).

On the other hand, Partings was expressed:

“With the parents, one by one we went to say goodbye to our patient, we held a minute of silence” (Participant #4).

Spirituality and religiosity as behaviors and reactions from nurses after a neonatal death is a subtheme that was describe as follows:

“They are little patients, tiny babies, that when they die, we know they go to heaven, so one feels calmness, we know they are going to be with God” (Participant #5)

The subtheme Bravery is expressed in behaviors and reactions from nurses after a neonatal death by the participants as follows:

“…but, at the same time, I have the courage, to be brave to hand over that baby, because as I repeat, it is an experience... to hand over their baby, it’s horrible” (Participant #7).

Third Main Theme: Attitudes of Nursing Professionals Regarding Family

The emotions, thoughts, and behaviors exhibited by nurses in response to families facing the death of a child reflect a set of attitudes that represent their natural reactions to this experience.

Awareness of these attitudes leads to greater subjective control and greater recognition for the profession.

The attitudes of nurses toward the families are diverse, and this relationship depends on the feeling related to parity. This line of thought led to this meaning:

“I felt that sorrow of knowing that she wanted to have her baby, her first and only baby, that she had, and I say that, at that moment, more pain, more sorrow” (Participant #6).

When a nurse is asked how she acted towards the family that had just lost their infant, she answered as thus:

“Calmly, it was explained what had happened, and the mother was left alone with the baby, I approached her to give her words of encouragement. It was normal, no crying” (Participant #2).

Fourth Main Theme: Intervening Factors in a Neonatal Death

The intervening factors are those aspects expressed by nursing professionals about neonatal death, and which have to do with: time of care, attachment or involvement and empathy, and which lead to a mixture of thoughts, reactions, feelings, and emotions.

The loss of a neonate is experienced uniquely and individually by each of the caregivers, despite the existence of common elements. Therefore, it can be said that the same loss has a different meaning for different nursing professionals, because each of them perceives it differently, depending on the sense and quality of care time, dependence or independence (attachment) that has been generated with the patient, and the emotional investment in the relationship established with the patient and/or family members.

About attachment, one participant indicated how it is signified by the time of care:

“It’s not the same when you get one and dies, as when you have one that has been with you and has been seen by you, for a long time” (Participant #1).

Fifth Main Themes: Personal, Professional, and Institutional Resources of Nursing Professionals during a Neonatal Death

During academic training and professional instruction, nurses receive sufficient knowledge to care for the sick, the healthy in their different scenarios, and even the dying and their families; however, too much emphasis is placed on promoting recovery, quality of life, and social restoration, but little emphasis is placed on self-care, management of one’s own emotions, and reaction control.

There is an urgent need to prepare, train, accompany, and guide from the individual to the collective, through the constitution and creation of specialized teams to address these experiences of pain, and to find ways of coping positively and constructively, that will result in good emotional drainage and, therefore, in personal enrichment. Likewise, the benefit is extensive in the attention and orientation to affected parents, the profession, and the institution. In the end, everything is an added value.

One participant expressed this need, as reflected in the following line of text:

“I think I was not prepared to approach them, especially because, at this moment, you do not know what to say in front of them, you do not know if what you are going to say will worsen the situation, I saw everything from afar, I did not get to express any words to them. Because, suddenly, I would say that what I am going to show them is not going to be something of strength, but rather, of sadness, so I think that I am not accomplishing anything” (Participant #10).

Discussion

The exploration of intensive care nurses’ experiences after neonatal deaths in Colombia revealed five main themes that aligned with the current literature. This study aimed to explore experiences of neonatal death from nurses, using a hermeneutic phenomenology approach and interpretation of interviews. Our findings showed that nurses experience different personal emotions, behaviors and attitudes for grieving. This may be varying according to their experience, length of stay of the neonate and parity, among others. The results of this research significantly intertwine the complexity of the study phenomenon as the meaning of grief for nurses in the context of care in NICUs. The results were centered on the emotions, behaviors, and reactions to grief experienced by nurses in the face of neonatal death. Likewise, attitudes intertwined with family relationships, intervening factors such as the time spent caring for the neonate, and the preparation or tools that the nursing professional has to be able to deal with grief in the face of neonatal death, emerged.

Although studies on nurses’ grief due to neonatal deaths are scarce, some come close.⁴ One study explored their experiences caring for families with perinatal loss,^17,22as well as the bereavement experience of nurses in other settings such as pediatric oncology,^23,24 the elderly,²⁵ and adults in the intensive care unit.²⁶

During perinatal death, nurses want to feel useful and alleviate the suffering of parents. However, a clear understanding of this situation can help nurses better understand their own experiences.¹⁷ Nurses often find it challenging to separate their personal and professional identities when caring for grieving families, which can result in compassion fatigue and even physical manifestations of stress. Consequently, implementing psychosocial and psychological support interventions is essential to promote their well-being. One study, using a group approach for pediatric intensive care nurses, showed that psychosocial and psychological interventions were effective in stress management. Therefore, there is a need to develop psychosocial support interventions for stress management.²⁷

The first main theme extracted from the findings was the emotions of nursing professionals caused by a neonatal death. Some of these can be emotions of pain, uneasiness, frustration, sadness, guilt, relief, helplessness, and loss. In a study by Kostka et al compassion, sadness, and helplessness are the most common types of nurses’ emotions caused by the death of patients, regardless of the nurses’ length of service and the place of work.²⁸

The second main theme of the research findings was behaviors and reactions after a Neonatal Death. Our findings show different reactions such as insensibility, spirituality, religiosity and bravery. Nurses mentioned not having received preparation for coping with bereavement. Rankin et al reported that current training and guidelines in the United Kingdom to support health professionals caring for parents who have experienced a bereavement are inadequate. Guidelines are needed for health professionals supporting parents experiencing bereavement.²⁹

The third main theme of the research was the attitudes of nurses regarding families. These attitudes are diverse, and this relationship depends on the feeling related to parity and length of stay. In Mateo et al study, taking care of dying patients and supporting their families is a difficult and stressful task for nurses who view death as one of the most challenging clinical experiences.³⁰ While family-centered care is central to acute care nursing, the COVID-19 pandemic raised challenges and priorities in the delivery of end-of-life care. A systematic review that sought to describe clinical practice interventions to support family-centered care in acute care during the COVID-19 pandemic identified family support and engagement, and systems to facilitate communication with families as key to care.³¹ An important finding of our research is that communication is central to the transmission of feelings and emotions between families and nurses. Therefore, the tools to strengthen communication in post-pandemic times need to be reinforced.

The fourth main theme of the research findings was intervening factors in neonatal death. Some of the factors are care time, attachment and empathy. The research by Kostka et al found that the way of coping with stress is related to the period of service and the workplace of nurses.²⁸

The fifth main theme, some nurses expressed a lack of training and resources at a personal, professional, and institutional level. This is similar to another study in which grief over patient death plays an overlooked role in direct care worker burnout.³² Because nurses experience a high level of stress and strong emotions triggered by the observation of dying patients, it is necessary to implement programs at the institutional level to help nurses out with neonatal deaths.

Hospitals where nurses work should have resources in place to help their staff deal with neonatal death. It is the nursing professionals who face this experience in a subjectively, hence, the reactions are significantly different.

This research work shows the need to prepare, train, accompany, and guide from the individual to the collective, through the constitution and creation of specialized teams to deal with these bereavement experiences. It is necessary to include personal coping scenarios in undergraduate and graduate study plans, as well as incorporate elements of simulated practices, which in turn provides an area of interest for research.

It is also necessary to establish well-delineated protocols in which it is clearly stated how to assist nurses in this situation, with psychological support teams.^4,17

There were no particular limitations for conducting this study. However, one the limitation of

qualitative research may be the inability of the findings to be generalized. To ensure sampling, nurses were selected using convenience sampling and result saturation. Another aspect is that male nurses did not participate, because all the nurses in the institutions were female. However, this is a common aspect in nursing as the majority are still female.

Conclusion

This research allowed an understanding of the phenomenon of neonatal losses, from the experience of nursing professionals, revealing facets of their approach. The nursing professional in the process of integral care of human beings lives the experience of facing the transition from life to death, both, for those who suffer from an illness, and for the loved ones around them. A warm, favorable, and supportive attitude is always expected from them, but many behaviors, emotions, and reactions arise when facing this process, which may reflect frustration, guilt, and helplessness due to the experience to which they are exposed, and for which they may not be prepared. Therefore, based on the results of this research, it is important to prepare and accompany the nursing professional in facing this grief, as well as establishing support networks within the discipline to deal with the coping of death with better results. This will allow for strengthening the accompaniment and guidance of the affected parents.

Competing Interests

The authors declare no conflict of interest.

Data Availability Statement

The raw data supporting this study (interview transcripts) are retained by the corresponding author and may be shared upon reasonable, justified request).

Ethical Approval

Ethical approval was obtained from the Ethics Committee of the National University of Colombia (code: UGI-01XX-XXX1), as well as authorization from the Research Committee of the participating hospitals. This study was conducted by the ethical norms and principles of research on human subjects.

However, authors confirm that informed consent was obtained from all participants, and all methods were carried out in accordance with relevant guidelines and regulations.

Research Highlights

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