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Greek nurse and physician grief as a result of caring for children dying of
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 Greek Nurse and Physician Grief as
a Result of Caring for Children
Continuing
Education
Dying of Cancer
Series Danai Papadatou
Thalia Bellali
This descriptive study explored and compared the grief responses
and experiences of Greek physicians and nurses who provide care to
children dying of cancer. Interviews were conducted with 14 oncolo-
gists and 16 pediatric oncology nurses. Data were subjected to a
combination of qualitative and quantitative methods of analysis. For
both groups, the dying process and death of children were highly
stressful experiences and triggered a grieving process. Differences,
however, were observed in terms of the way these two groups (a)
perceived the loss of the child and (b) expressed or avoided their
grief. It became apparent that health professionals' grieving process
was affected by how they perceived their role, interventions, and
contribution in the care of the dying child, which in turn was influ-
enced by the social and cultural context in which care is provided to
children with cancer. Findings suggest that despite the distress
caused by children's death, both nurses and physicians identified
specific rewards they reaped from caring for children who are termi-
nally ill.
I
t is widely accepted that caring for
patients vi/ho are terminally ill is a
demanding and difficult task.
Much attention has been given to
the stress that health care professionals
experience when caring for adult
patients, and a number of personal and
work-related factors have been identi-
fied as contributing to professional dis-
tress and burnout (Chiriboga, Jenkins,
& Bailey, 1983; Jenkins & Ostchega,
1986; Papadatou, Anagnostopoulos, &
Danai Papadatou, PhD, is Professor of Monos, 1994; Vachon, 1986, 1997;
Clinical Psychology, School of Mursing, Yasko. 1983). Unfortunately, consider-
University of Athens, Greece. ably fewer studies explore the distress
of professionals who provide care to
Thalia Beliali, MSc, RN, is a nurse, Amaiia
Reming Hospital, Athens, Greece.
dying children, even though it is recog-
nized that such care evokes intense
Irene Papazoglou, MSc, is Psychologist, fear, increased feelings of helplessness,
"Merimna" - Society for the Care of and a spiritual quest for meaning in a
Children Facing Illness and Death, Athens, death that is often perceived as revers-
Greece. ing the order of nature (Oehler &
Davidson, ! 992). According to
Dimitra Petraki, MSc, RM, is a nurse. Kushnir, Rabin, and Azulai (1997), the
t-aiko Hospital. Athens, Greece. major source of occupational stress
among pediatric nurses is their preoc-
Acknowledgment: This work was support- cupation with the death and dying
ed by grants from the University of Athens, process of young patients.
Greece.
Recently, there has been a shift from
the study of stress and burnout to the
The CE Posttest understanding of professionals' respons-
can be found es to the death of children as grief man-
on pages 363-364. ifestations (Davies et al., 1996; Hinds et
PEDIATRIC NURSING/July-August 2002/Vol. 28/No. 4 |
Irene Papazoglou
Dimitra Petraki
al., 1994; Papadatou, Martinson, &
Chung, 2001; Rashotte, Fothergrill-
Bourbonnais, & Chamberlain, 1997).
Davies and colleagues (1996) studied
the responses of pediatric oncology
nurses and identified a number of strate-
gies they use to handle their distress
over the death of their young patients.
Strategies that facilitated adjustment
involved the open expression of grief
and the attribution of meaning to the
child's death. Furthermore, peer support
and a sense of being valued were identi-
fied as conditions that enhanced nurses'
coping. By contrast, the personal or
work-related expectations that did not
allow the expression of grief constrained
nurses' coping with patient loss. The use
of various coping strategies in dealing
with distress had personal and profes-
sional implications that affected both
their involvement with dying children as
well as their self-perception.
Papadatou, Martinson, and Chung
(in press) recently studied the experi-
ences of nurses who provide care to
dying children in pediatric oncology
and critical care units in Greece and
Hong Kong. Findings revealed that
regardless of work or cultural setting,
nurses experience a grieving process
characterized by a fluctuation between
two psychic processes: one involves
the experiencing and expression of
grief; the other, the avoidance or
repression of grief by moving away
from the loss experience. This fluctua-
tion process is normal, healthy, and
adaptive, as it allows health care pro-
fessionals to grieve without being
overwhelmed by the loss experience
(Papadatou, 2000).
The purpose of this descriptive
study was to further explore the griev-
ing process and compare the subjec-
tive experiences of physicians and
nurses who provide care to children
dying of cancer in Greece. More par-
ticularly, the authors were interested in
answering the following questions: (a)
What motivates professionals to work
with seriously ill children? (b) What
challenges do they encounter while
caring for dying children? (c) How are
they affected by children's death? and
(d) What are some of the factors that
 Table 1. Demographic Information
Nurses
(n = 16)
Gender
Female 94% (15)
Male 6%(1)
Age
21-30 31% (5)
31-40 56% (9)
41-50 13% (2)
>50 0% (0)
Nurse Education
2 years 31% (5)
3 years 56% (9)
4 years 13% (2)
Marital Status
Married 50% (8)
Divorced 6% (1)
Single 44% (7)
affect their desire to stay or leave this
particular field of work in which expo-
sure to childhood death occurs more
frequently than in many other fields of
nursing?
This study was both a part, as well
as an extension of, a transcultural
study conducted with nurses who
worked in pediatric oncology and
intensive care units (Papadatou,
Martinson, & Chung, in press). Results
from the initial study invited the
authors to further explore the similari-
ties and differences between Greek
nurses and physicians in terms of how
they perceive and experience the
dying process and death of children.
Quite recently, the concepts of
"grief and "mourning" have been the
objects of redefinition and debate in
the literature. Rando (2000) and Corr,
Nabe, and Corr (1997) suggest that
grief is the reactive response to loss,
while mourning encompasses a series
of actions undertaken to accommo-
date the loss within a person's life. By
contrast, Stroebe and Schut (1998)
define mourning as "the social expres-
sions or acts, expressive of grief,
which are shared by the practices of a
given society or cultural group" {p. 7).
In this study, the authors chose to
define grieving as the process that
comprises a person's grief responses
and coping strategies in his or her
attempt to adjust to an experience that
is perceived as a loss and accommo-
dated It into one's life.
Methodology
Cultural context of the study. The
Physicians TOTAL
(n = 14) [N =30)
64% (9) 80% (24)
36% (5) 20% (6)
0% (0) 17% (5)
23% (3) 41% (12)
62% (8) 35% (10)
15% (2) 7% (2)
0% (0) 17% (5)
0% (0) 30% (9)
100% (14) 53% (16)
86% (12) 67% (20)
3% (1)
0% (0)
14% (2) 30% (9)
cultural and social context within
which this study was conducted pre-
sents some features that are quite dis-
tinct from the cultural and social con-
text within which care is provided to
the dying in other western countries.
In Greece, when a child Is diagnosed
with cancer, both health care profes-
sionals and parents inform the patient
that he or she is suffering from a
chronic and serious health condition.
However, they rarely give a name to
this disease. Cancer continues to be
strongly associated with death, and
the social stigma attached to it often
leads families to hide the truth both
from their children and their social
network. The secrecy about the child's
condition becomes even more pro-
nounced when he or she experiences
repeated relapses or when he or she is
dying.
At this terminal phase, parents are
faced with the option of receiving care
in the hospital or returning home and
assuming the total responsibility of the
patient's care, since no pediatric hos-
pice or home care services are avail-
able. Usually the child's request and
parents' preference determine the fam-
ily's decision. If the child returns home,
care becomes a "family affair," and
even though it is highly stressful for
parents, the experience is generally
perceived as a positive (Papadatou,
Yfantopoulos, & Kosmidis, 1996). The
child who is cared for in the hospital
receives the services from familiar
members of the oncology multidlscipli-
nary team, In Greek educational set-
tings, most of these team members do
_PED1ATRIC NURSING/Juiy-August 2002/Vol. 28/No. 4
not receive any specialized training in
palliative care during their basic educa-
tion in nursing, medicine, psychology,
or social work. During the past few
years, however, these professionals are
increasingly exposed to training pro-
grams, lectures, and biannual seminars
that address topics related to pediatric
psycho-oncology and pediatric pallia-
tive care (Papadatou, 2001 a). This
form of ongoing education is critical,
especially since most nurses are
assigned by the hospital administration
to work in these units in contrast to
physicians who choose this particular
field of work.
Sample. There are four major pedi-
atric oncology units in Greece. Two of
them - the oldest and largest - are sit-
uated in the two largest pediatric hos-
pitals in Athens. Since their founding
in 1987 and 1989, they have treated
over 3,500 children with cancer. The
authors approached these two units
and interviewed 30 health care profes-
sionals: 14 physicians who worked in
both pediatric oncology units in
Athens, and 16 nurses who worked in
one of the two pediatric oncology
units. All physicians and nurses of the
respective units were approached and
invited to a personal interview with the
principal investigator (Papadatou),
lasting from 60 to 90 minutes. The
response rate was 100%, probably due
to the fact that the principal investiga-
tor's work in pediatric oncology is well
known and widely accepted in Greece.
The sample included 15 female
nurses (94%) and 1 male nurse (6%),
and 9 female physicians (64%) and 5
male physicians (36%). The mean age
of physicians was 46 years and of
nurses was 34 years. The majority of
the respondents (67%) were married
with most physicians having one to
two children and half of the nurses
having no children. Thirteen percent
of the nurses had a 4-year undergrad-
uate nursing education at the universi-
ty level, 56% had a 3-year education
at a technical nursing institution, and
31% had 2 years of occupational train-
ing in nursing (see Table 1).
Physicians had completed 6 years of
education in medicine, followed by 4
years specialization in pediatrics, and
were further specialized in pediatric
oncology or hematology, mostly in the
United States.
Data collection. A semi-structured
interview was conducted with each
nurse and physician, during which
open-ended and a few closed ques-
tions were asked. Questions were
organized around three major themes:
(a) motivation to work in this field
(i.e., personal experiences with ill-
 Table 2. Most and Least Stressful Conditions as Perceived by Physicians and Nurses

MOSTSTRESSFUL LEAST !STRESSFUL

Nurses % Physicians % Nurses % Physicians %

Be present at the moment of death 28.6 28.6 31.2 21.4

Provide care to a dying child who

is in a coma 7.1 7.1 71.4 42.9

Provide care to a dying child who

is in pain and is suffering 71.4 78.6 0 0

Provide care to a child who dies unexpectedly 50 64.3 7.1 7.1

Provide care to a dying child you know

for a long time 50 14.3 7.1 21.4

Provide care to a dying child whom you do not know 7.1 50 85.7 21.4

Provide care to a dying child who has the same

age as your own children or reminds you
of a relative or friend 35.7 21.4 14.3 21.4

Provide support to parents during the terminal period 28.5 0 7.1 64.3

Provide support to parents who grieve over the

death of their child 14.3 0 35.7 64.3

Deal with the demanding parents of a dying child 14.3 35.7 35.7 35.7

ness/death; factors affecting their
decision); (b) challenges and respons-
es {i.e., stressors and rewards, person-
al coping with dying and death); and
(c) satisfaction with work (i.e.. factors
affecting desire to stay or leave the
field of pediatric oncoiogy, degree of
job satisfaction). These themes were
based upon the four research ques-
tions that guided the initial study.
Moreover, the researchers attempted
to determine the conditions that lead
to a certain situation (e.g., working in
a field where childhood death occurs
more frequently than in many other
fields of nursing), the actions/interac-
tions undertaken to cope with repeat-
ed deaths, and, finally, the possible
consequences as a result of these
actions/interactions.
At the end of the Interview partici-
pants were presented with a list of 10
stressful conditions related to different
aspects of the care they provided to
the dying child and to the grieving par-
ents. This list of stressful conditions
comprised the following items, out-
lined in Table 2:
1. Being present at the moment of
death
2. Providing care to a dying child In a
coma
3. Providing care to a dying child
who is in pain and is suffering
4. Providing care to a child who dies
unexpectedly
5. Providing care to a dying child
you have known for a long time
6. Providing care to a dying child
whom you do not know
7. Providing care to a dying child
who is the same age as your own
children or who reminds you of a
relative or friend
8. Providing support to parents dur-
ing the terminal period
9. Providing support to parents who
grieve over the death of their child
10. Dealing with the demanding par-
ents of a dying child
Participants were initially asked to
carefully read all 10 conditions, and,
subsequently, they were invited to
organize them in hierarchical order
from 1 (least stressful) to 10 (most
stressful) in terms of the level of dis-
tress each of them caused the respon-
dent.
Method of analysis. A combination
of both qualitative and quantitative
methods of analysis was used. This
mixed methodology has been used in
many studies for supplementary and
informational reasons (INeimeyer &
Hogan. 2001; Strauss & Corbin, 1998;
Thorson, 1996). Due to the nature of
the phenomenon under study, the
authors chose to use primarily the
qualitative method, which, according
to Strauss and Corbin (1998), is used
to gather details about feelings and
thought processes that are difficult to
obtain through conventional research
methods. In other words, the goal of
the qualitative method is "to discover
and explore the unique and common
perspectives of the individuals being
studied" (Meimeyer & Hogan, 2001).
Qualitative methods are considered
valuable in generating theory, in
revealing how people make meaning
of events, and in leading to a deeper
understanding of phenomena that
have not been sufficiently studied
(Heimeyer & Hogan, 2001).
Qualitative analysis is a non-math-
ematical process of interpretation
used to discover concepts and rela-
tionships in raw data, leading to the
formulation of a theoretical construct
(Strauss & Corbin, i 998), The authors
chose the grounded theory approach,
which is the most widely used qualita-
tive method of analysis, Grounded
theory is defined as a method in which
"the processes and products of
research are shaped from the data
rather than from preconceived, logi-
cal, deduced, theoretical frameworks"
(Charmaz, 1983, p. 1 10).
The four levels of analysis that con-
stitute the process of grounded theory

PEDIATRIC NURSING/July-August 2002/Vol. 28/Np. 4

were used (Chenitz & Swanson, 1986).
The first level consisted of the system-
atic presentation of the data gathered
from the interviews. The second level
led to the generation of categories that
organized these data. The main cate-
gories derived were (a) motivation to
work in the field, (b) decision to work in
the field, (c) stresses related to the care
of the dying, (d) perceived rewards, (e)
nature of perceived loss(es) related to
patient death, (f) responses to per-
ceived loss(es), (g) meaning attribution
to childhood death, (h) nature of sup-
port provided, (i) satisfaction with work,
and (j) desirability to stay or leave the
unit. The third level comprised the
incorporation of the identified cate-
gories into "core" categories. The two
core categories that were derived from
the professionals' responses to the
death of their patients were "grieving
process" and "mutual support." The
properties and dimensions of the core
categories as well as their relationship
to the identified categories were
explored. "Mutual support" was ana-
lyzed and presented in a previous pub-
lication (Papadatou, Papazoglou,
Petraki, & Bellaii, 1999). At the fourth
level of analysis, the "core" categories
were integrated into a theoretical
scheme, which led to the formulation of
a model regarding the grieving process
of health professionals described by
Papadatou (2000, 2001b).
Quantitative techniques were used
to analyze data obtained through the
list of 10 stressful conditions that was
designed for the purposes of the pre-
sent study. This list helped to highlight
some of the differences and similari-
ties between study groups in their per-
ceptions of stress- related sources.
Results
Decision to work in pediatric
oncology/hematology. The large
majority of physicians in the sample
(70%) chose to pursue medical stud-
ies because of social influences.
Medicine was perceived as a presti-
gious and financially secure profes-
sion. The decision to study medicine
was also the result of circumstantial
factors such as having one's closest
friends go into medicine or having
excellent grades in high school, a fact
that creates an expectation that one
must pursue a high standard career.
For half of the sample, the choice to
specialize in pediatrics was deter-
mined by their love for children. Their
decision to further specialize in pedi-
atric oncology and/or hematology
was mostly motivated by their scientif-
ic interest in a complex disease per-
ceived as a "challenge." Many physi-
cians reported to be challenged by the
possibility to cure and contribute
toward saving a child's life, while oth-
ers were challenged by the opportuni-
ty to accompany chronically ill chil-
dren throughout their illness.
Although physicians consciously
decided to work in pediatric oncolo-
gy/hematology, the majority of nurses
did not choose this field of work. Most
of the nurses (61%) were assigned by
the hospital administration. This prac-
tice is quite common in Greek hospi-
tals, which are understaffed in terms
of nursing personnel. These nurses
reported that they initially felt unhap-
py and anxious because they were
placed in an oncology unit, and were
highly concerned with the severity of
children's condition as well as with the
emotional impact that such care
would have upon them. However,
within a short period of time they
reported to overcome their reserva-
tions.
Terminal care. A number of ques-
tions addressed the issue of terminal
care. Some questions involved (a) the
difficulties encountered during the ter-
minal phase, (b) the stressors and
eventual rewards, and (c) the profes-
sionals' presence and response to the
death scene.
Difficulties. The qualitative analy-
sis brought to light two main cate-
gories of responses: (a) difficulties
related to the dying conditions and
death and (b) difficulties related to
communication problems encoun-
tered with children and parents
throughout the terminal phase.
Physicians and nurses reported diffi-
culties in both categories.
Findings revealed that for the
majority (57%), the dying process and
death of a child were sources of major
difficulty and distress. In both groups,
death triggered a sense of helpless-
ness and powerlessness that was the
result of their inability to decrease, in
some cases, the physical and emo-
tional suffering of patients and families
or the irreversibility of dying and death
per se, "To care for a child in pain and
being unable to help," said a nurse,
"makes me feel powerless" (female,
36 years old). While a physician
reported, "When I realize that i can do
nothing but accept the child's dying
process, I begin to feel helpless"
(female oncologist, 47 years old). This
sense of helplessness was even more
pronounced among physicians who
felt that neither medically, nor psycho-
logically could they offer anything of
value. Their perceived role was being
annulled as illustrated in the following
account:
PEDIATRIC NURSING/July-August 20q2/Vol. 28/No. 4
"The most difficult aspect for me is
when they all expect me to do some-
thing, yet I do not know what. In real-
ity it's not dealing with death anxiety,
but rather, with being there, unable to
do anything and feeling medically
and emotionally helpless and power-
less" (male oncologist, 33 years old).
The second most frequently report-
ed difficulty (43%) related to terminal
care involved communication issues
with children and parents. Both nurses
and physicians often reported to be at
a loss for words, especially when
dying children raised questions about
their prognosis. "When they (chil-
dren) ask me 'what's my Illness? Will
I yet better?' I don't know what to
answer. I feel helpless," reported a
nurse (female, 31 years old). As
already mentioned, in Greece, even
though children are informed about
the seriousness of their disease, they
are not told that this is a form of can-
cer, and both parents and health care
professionals shield them from the full
reality (Papadatou et al., 1996). While
communication difficulties with chil-
dren were related to the disclosure of
truth, communication difficulties with
parents were related to their psycho-
logic support, as expressed in the fol-
lowing account, "/ manage to keep a
certain distance, because I am deeply
affected during Lhe terminal period. I
ought to say something to the parents
but 1 am at a loss for words" (male
oncologist, 48 years old).
Sources of stress and rewarding
experiences in terminal care.
Oncologists and nurses were asked to
organize, in hierarchical order, 10
stressful conditions in terms of the dis-
tress each of them caused the respon-
dents. Conditions that were hierarchi-
cally situated by physicians and nurs-
es in positions 10, 9, and 8 were con-
sidered "most stressful," whereas
those situated in positions 1, 2, and 3
were considered as "least stressful."
As shown in Table 2, for the majori-
ty of physicians (78.6%) and nurses
(71.4%), caring for a dying child who is
in pain is considered as highly stressful.
Similarly, for most physicians (64.3%)
and half of the nurses (50%) the unex-
pected death of a child is also consid-
ered highly distressing. Distinct differ-
ences between study groups were
found in the stress caused by the care
of a child with whom they had a long-
or short-term relationship. More partic-
ularly, for 50% of the physicians, the
care of the dying child they hardly
knew caused increased distress. In
contrast, most nurses (85.7%) consid-
ered this same condition as least
stressful. Interestingly, for half of the
nurses (50%) the care of a child with whom they had a long-
standing relationship triggered intense distress, in opposition
to physicians who were less distressed. Physicians explained
that they had exhausted all available protocols in the pursuit
of cure and finally accepted the child's condition as terminal.
Despite the above mentioned stressors, caring for dying
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children included significant rewarding experiences as well.
The major source of satisfaction (43%) for physicians was
related to symptom management, particularly pain control,
and physical comfort. "Forme, "said an oncologist, "thegreat-
est satisfaction is to see the child depart (die) without suffer-
ing" (female, 46 years old). The lack of physical suffering
seemed to be a priority for physicians and a rewarding expe-
rience. When they were unable to control the child's symp-
toms, they experienced high distress, and. as previously stat-
ed, they described this situation as being a major difficulty in
the provision of terminal care. Other physicians (36%) derived
satisfaction from a personal relationship they had developed
with children and parents, while few (21%) from having their
contribution acknowledged by parents.
For nurses, satisfaction involved a sense of contribution
that was related to the provision of physical and psychoso-
cial care in the face of death (38%), the close relationship
they shared with some children and parents (31%), and the
recognition they received from families for their contribution
to the care of the dying. Some (25%) felt they were offering
something very unique, special, and quite distinct from their
colleague nurses working in different units and who did not
encounter death with great frequency.
It became apparent that physicians derived satisfaction
primarily from their ability to control a child's pain and the
provision of effective medical care, while nurses derived sat-
isfaction concurrently from the physical care, the psychoso-
cial care, and the support they offered to dying children and
to their parents. For both groups, satisfaction also was relat-
ed to the close and special relationship they developed with
children and parents throughout the illness and the terminal
phase. Only a few professionals (10%) were unable to iden-
tify any rewards related to terminal care.
Presence at the death scene. Both nurses and physicians
tended to be present at the moment of a child's death. Forty-
three percent (43%) of the physicians chose to be present,
especially when they had shared a close relationship with a
child, "if something happens (death) I feei a void if i'm not
there," said a physician (male, 65 years old). Another one
Do more.
reported, "Fortunateiy, many of the children I tooed died in
my hands; it helps me to know i was there for them. The
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majority perceived the washing and dressing of the child's
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se, was not the most stressful experience for nurses. It was
the absence of a colleague during the night shift that caused
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identify and describe their grief reactions. Findings revealed

PEDIATRIC NURSING/July-August 2002/VoL 28/No. 4

that the large majority of both physi-
cians (82%) and nurses (94%)
acknowledged that they were grieving
over the death of children, particularly
over those with whom they had shared
a close relationship throughout their
illness. Characteristic of their grief
process was a fluctuation between
experiencing and avoiding grief,
described in other publications
(Papadatou, 2000). However, they
displayed differences in the way they
expressed their grief, as well as in the
fluctuation pattern of their grieving
process.
Experiencing grief. Physicians'
grief reactions involved crying, sad-
ness, withdrawal, and recurring
thoughts of the dying conditions and
the death of the child. They frequently
reported guilt feelings and an active
search for philosophic explanations
that would make their distress more
tolerable. They rarely sought support
among colleagues and experienced
grief as a private affair.
"My role ends when I dose the
child's eyes and bring the parents into
her or his room. Afterwards I leave; I
go downstairs (to my office) for an
hour or so. I may listen to music. I will
do my grieving. / will think about the
child's death," reported a physician
{male, 48 years old) as he described
his grief. Another mentioned, "(I
grieve) at home, t do it at home, on my
own, I sit in the dark, by myself and
tvork it out" (female, 51 years old).
Sharing experiences with col-
leagues seemed to be hindered by
various communication and coopera-
tion difficulties that existed within the
medica! team, as reported by the
majority of physicians (73%) who felt
that their colleagues were not emo-
tionally supportive.
hurses' predominant grief reac-
tions also involved crying, sadness,
anger, and recurring thoughts of the
dying conditions and the death of the
child. They frequently reported a ten-
dency to withdraw into themselves.
However, unlike physicians, they
referred to their need to share experi-
ences with colleagues to find an emo-
tional outlet, receive support, and
attribute meaning to the death of a
child.
The majority of nurses (75%) felt
emotionally supported by their col-
leagues, as a result of which grieving
was not only experienced at an indi-
vidual level, but at a collective level as
well. For nurses, grief had a predomi-
nant social element, while for physi-
cians grief was quite a lonely and indi-
vidual process. Whenever a nurse had
not witnessed a child's death, he or
she had the opportunity to grieve over
that loss during the sharing that
occurred among members of the
nursing team. Grieving was acknowl-
edged and experienced as an ongoing
process reported by a male nurse who
said, "Grieving over the death of the
child does not end the day after his or
her death. Every day something the
child did or said comes to our niind.
There is a continuous relocation of the
loss: there is a continuous stirring"
(male nurse, 28 years old).
Aooiding and repressing grief. All
care providers avoided or repressed
their grief at different times and to var-
ious degrees. This was accomplished
through the conscious control of dis-
tressful feelings, through the displace-
ment of their attention to practical
duties and clinical responsibilities, and
through their physical withdrawal from
distressful conditions surrounding the
death of a child.
Physicians reported avoidance
reactions with greater frequency than
nurses did, "When a child dies I roll
down the blind. I stay there as a
physiciati," reported an oncologist
(female, 49 years old), while another
said, "/ don't grieve, on the contrary, I
become fully involved in life, i try to
find friends, to get out. I don't mention
what I have experienced at work that
day. / try to think about it as little as
possible" {female, 46 years old). The
latter account shows how some pro-
fessionals engage in certain forms of
social encounters to avoid dealing
with their losses and grief.
The motives for such conscious
grief avoidance were to protect them-
selves from being overwhelmed by
multiple deaths, from re-experiencing
traumatic death experience, or from
having to confront their own mortality
and vulnerability. Such control was
also reinforced by the implicit work-
place ethic that did not allow the
expression of intense emotions among
members of tbe medical team.
Physicians controlled the fluctuation
between experiencing and avoiding
grief in a more systematic and struc-
tured manner than nurses did. They
developed personal strategies delin-
eating the degree, timing, and method
of their engagement and disengage-
ment with a dying child, as illustrated
in the following account: "When the
child startB to lose the battle I still go
into his room but iviten I realize the
child is close to death i don't (go); I
avoid it. I return when the child is
dead. I want to see him dead, to grasp
and come to terms with his death"
(female oncologist, 45 years old).
Another oncologist reported, "When
PEDIATRIC NURSING/July-August 2002/Vol. 28/No. 4
you are the master of the game you
have to be self-controlled. Of course
you get emotional, but you don't lose
your self control. Each of us develops
a routine of actions artd words. We do
things to keep us functional, alert,
without too much emotion. Later we
may withdraw to be on our own"
{male, 39 years old).
It also became apparent that each
group grieved over different types of
losses. Physicians grieved primarily
over the loss of their professional
unfulfilled goals and expectations to
cure the child, whereas nurses grieved
with greater frequency over the loss of
a special relationship they had devel-
oped with a particular patient.
Meaning making in the face of
childhood death. The attribution of
meaning to death is a central aspect of
the grieving process (Neimeyer,
2001). In this study professionals were
asked to explain and make sense of
the deaths they encountered. Their
responses were clustered in the fol-
lowing categories: (a) death is under-
stood as the consequence of a fatal
disease; (b) death Is understood as the
result of fate, pure chance or as part of
life's cycle; (c) death is understood as
the result of the will of a higher force;
and (d) death cannot be understood at
all, it has no meaning.
Most nurses had difficulty explain-
ing the meaning of children's death,
and the interview seemed to act as an
opportunity to put their beliefs into a
context. They experienced such diffi-
culty because they perceived death as
unfair. However, they readily attributed
meaning to their personal contribution
to the dying child's care and support.
Physicians responded more readily by
referring mostly to biologic and scien-
tific explanations. For most of them,
death acquired meaning If they had
exhausted ail possibilities to save a
child's life throughout his or her illness
and had contributed to a good death
by controlling his or her physical dis-
tress and symptoms.
Difficulties related to the grieving
process. Psychologic difficulties
occurred when there was a persistent
lack of fluctuation between experienc-
ing and avoiding one's grief, and,
therefore, professionals seemed to be
submerged into their grief or to be sys-
tematically avoiding it (Papadatou,
2000). In both circumstances the
process of working through loss was
significantly compromised and led to
various degrees of burnout, which was
expressed in accounts such as: "/
think that I age quickly, both biologi-
cally and psychologically as a result
of this work. My resistance has
 decreased. Smiling was once a characteristic of my person-
ality. Now. I experience a pressure upon my heart, a weight
that does not allow me to breathe" (female oncologist, 45
years old). Another professional reported, "It is the accumu-
lation of so many experiences over so njany years. I don't
laugh easily. ! am not enjoging myself I am no longer care- Aventis Pasteur T Aventis
free. I feet overwhelmed. It is as if t haue tat<:en in so much
sorrow, a sorrow which is not concrete or tangible in a way
that you could place it opposite you and t<:ill it" (female
oncologist, 43 years old).
A few professionals who experienced high degrees of
burnout used massive avoidance strategies to protect them-
selves from the experience of suffering and pain caused by
childhood death. These avoidance strategies were evident in
expressions such as: "Now I don't want to be close to any
dying child or family;" "I feel nothing;" "I close my pain in a
little drawer. I don't let myself think;" "I switch off and avoid
all images of what I have witnessed;" and "I draw the cur-
tain."
Satisfaction with work in pediatric oncology. Physicians
and nurses were asked whether they would remain or
change work setting, if they were given a choice. Only 35,7%
of the physicians, by comparison to 62.5% of the nurses,
were affirmative in their expressed desire to remain in the
pediatric oncology unit, while the rest were undecided or
expressed the desire to change work setting, if given a
choice. It is interesting to note that even though most of
oncology nurses (81%) were assigned by the hospital
administration to the oncology unit, the majority were very
clear in their desire not to change the object and setting of
their work.
For both nurses and physicians, the main motive under-
lying their desire to stay was their overall sense of satisfac-
tion for contributing something of value and of significance,
which was recognized regardless of whether children were
cured or died. In addition, nurses reported the intimate
nature of the relationships they developed with children and
parents as a major source of satisfaction in their work.
Physicians (42.8%) and nurses (18.7%) who said that
they would change unit of work, if given a choice, justified
their responses in a distinct way. Physicians referred to seri-
ous problems of collaboration among members of the med-
ical team that made them wish to leave their work setting,
Learn
while nurses referred to some problems of collaboration with
physicians and the shortage in nursing personnel. Of inter-
about vaccines.
est is that caring for dying children and grieving over chil-
dren's death was never reported as a reason for wishing to
In less time. On-line.
leave the pediatric oncology unit. However, some of the ® Order from the full tine of Aventis Pasteur vaccines
communication and collaboration difficulties experienced on a secure web site
among members of the team may be indicative of physi-
cians" and nurses' difficulty in processing their losses and ® Access account balances, purchase and payment
grieving at a team level. However, this hypothesis warrants records, CPT'' codes, product supply alerts, vaccine
further research. and disease information

Discussion © Hyperlink to vaccine information web sites

The results of this descriptive and exploratory study con-
firmed findings of previous studies suggesting that profession-
als grieve over the death of a child (Davies et al., 1996;
VaccineShoppe.com
Papadatou, 2000; Papadatou, Martinson, & Chung, in press). It's click and easy™
Moreover, it elaborated on the various grief responses experi-
enced by physicians and nurses who provide care to dying
children with cancer. Log on today!
The comparison between nurses and physicians revealed Aventis Pasteur Inc,
several similarities. Both groups described the dying process CPT Is a registered
Discovery Drive • Swiftwater PA 18370
iradBmartf of the American
and death of a child as a highly stressful experience trigger- Medical Associalion.
www.us.aventispasteur.com
ing off an increased sense of helplessness and a grief
process. Despite their distress, they seemed to derive con- ^^D0^ Avenlls Pastsui Inc Printed in USA
siderable satisfaction from contributing to a dignified death.

PEDIATRIC NURSING/July-August 2002/Vol. 28/No. 4

Moreover, both groups acknowledged
that they grieved in the face of child-
hood death and described a number of
comnnon responses that presented a
pattern of fluctuation between experi-
encing and avoiding grief. The same
fluctuation process also was observed
in the transcultural study conducted
between Greek and Chinese nurses
who work in pediatric oncology and
critical care settings (Papadatou,
Martinson, Chung, in press).
Differences between study groups
were mostly related to the way physi-
cians and nurses expressed their grief.
It was emotionally distressing for
physicians to be in the room when a
chiid was dying because they felt
helpless and unable to be medically
useful. Physicians grieved more often
over the loss of their unmet profes-
sional goals and expectations, and
their grief was experienced more as a
private process. They rarely sought
emotional support among colleagues
and seemed to systematically repress
their grief to avoid being overwhelmed
by it.
Murses derived satisfaction from
developing a personal and mutual
relationship with the children and their
parents more frequently than physi-
cians. The nature of this relationship
enabled them to accompany children
and to invest with meaning their pro-
fessional role in the face of death. For
most nurses, the death of a chiid was
primarily experienced as the loss of a
special relationship triggering a griev-
ing process. These nurses usually
sought support among colleagues
with whom they shared personal
experiences.
Greek physicians and nurses in this
study perceived quite differently their
role and intervention in the care of the
seriously ill child. This may be due to
differences in their basic training,
which is largely biologically-oriented
for physicians and more biopsychoso-
cially-oriented for nurses. Some of the
differences in the fluctuation process
between experiencing and avoiding
grief may be affected by factors relat-
ed to the work environment (e.g., the
unit's philosophy, the team's unspo-
ken rules regarding what constitutes
an appropriate professional behavior
for nurses and physicians in the face
of death),
Study findings need to be under-
stood in relation to the social and cul-
tural context within which they occur,
and caution is suggested toward
potential over generalizations. Some
sources of stress that professionals
experienced were directly related to
the work conditions they faced (e.g..
shortage of nursing staff, team com-
munication problems) or to the
unavailability of organized and com-
prehensive palliative care services for
children in Greece (Papadatou,
200 la). Even though professionals
acknowledge their grief, Greek society
expects them to remain "strong" and
"brave" in the face of death and disen-
franchise their grief. For physicians
that grief remains hidden, while for
nurses it is expressed within the con-
fines of their unit.
The implications of the findings at a
clinical level suggest that to cope
effectively with the death of young
patients, healthcare professionals
need to accept their grieving process
and its fluctuations between experi-
encing and avoiding loss and pain as
a natural response to death. In that
respect, consultation, support, or
other forms of interventions that may
facilitate grieving can only be of value
if developed in response to the specif-
ic needs identified by nurses and
physicians in a given unit (Papadatou
etal., 1999),
At an educational level, health care
providers need to be taught how to
implement the principles of palliative
care and how to develop a sense of
competence in their biopsychosocia!
role, which allows them to effectively
address the complex needs of dying
children and their families. Basic train-
ing should offer opportunities to
explore their personal attitudes
towards death and dying and define
the goals of their interventions in the
face of death (Papadatou, 1997;
Shanfield, 1981).
Finally, further studies are needed
to elaborate on the unique features of
the grieving process experienced by
healthcare professionals. Moreover, it
would be of interest to further explore
how a number of identified personal
variables, patient-related variables,
and work-related variables interact,
and how they affect the grieving
process over time.
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