Cognitive-behavioral therapy for insomnia in hospice nurses

¶ … hospice nurses cope with patients at end of life and death?

Nursing is an emotional job since nurses' experience emotions and feelings towards their patients. On top of having the clinical skills of nursing, end-of-life care requires skills to deal with the patients as well as their relatives. Therefore, the nurses must be mature emotionally. Some of the nurses create an emotional distance by avoiding discussions regarding their patients' concerns and emotional problems (Peters et al., 2013). In the past thirty studies, several studies have looked into the issue of death anxiety. This can be regarded as a feeling of fear, dread, anxiety when one thinks of death, or anything associated with it. This is a common phobia among many people. In their work, nurses face situations of death of patients, under their care. How they serve people who are in the last stages of life could depend on their personal feelings and attitudes towards the issue of death. Nurses therefore require experience and skills that will help them to check their fears and emotions when they find themselves in emotional situations like death. This study will discuss the strategies that nurses require to cope and serve hospice patients.

a) Statement of the problem

Hospice nurses are exposed and even involved in a patient's process of dying. In a qualitative study that was among the first to look into the how oncology nurses who take of dying patients are affected, it was found that a special personal bond develops between the patients and the nurses. The nurses then decide to play a part in the dying process of the patient. There are positive and negative effects of chronic exposure to the process of death. More isolation, somatization and sadness was found in oncology nurses who directly handled dying patients; acute care nurses, however, handled chronic losses maintaining a distance between themselves and the dying patients as well as sustained self-care (Carter, Dyer & Mikan, 2013). Nurses are affected by a patient's death in different extents. However, all the reviewed studies showed that nurses exposed to multiple deaths had a higher risk of negative health outcomes. Regardless of this revelation, the effects of recurring lack of sleep for hospice care nurses are still unknown. Consequently, the aim of the pilot study is to explore the viability of a cognitive-behavioral therapy for insomnia (CBT-I) among the nurses in the hospice department.

c) Justification

Nurses who are suffering tend to focus on the physical symptoms they experience. They often suspend life tasks and interpret their symptoms negatively. This increases their distress psychologically. The concern about their life circumstances and symptoms drains them emotionally thus decreasing their coping ability. This leads to increased situational vulnerability as well as a sense of uncertainty. As functional ability reduces and distress increases, it gets connected with the sense of approaching death and the sufferer starts to feel isolated. Most of the time, the sufferers view themselves as having lost their self-perspective (Sacks & Volker, 2015). From the point of "being a burden," they explain how roles and relationships have changed. This causes the need to establish strategies to cope and ensure that the output of the nurses is optimized.

d) Research Questions

What are the importance and status of the nurses' need to cope?

How is the general output of the nurses affected by their ability to cope?

Are there any systems and strategies that can assist the nurses to cope with a patient's death?

2) Review of The Evidence

a) Review of evidence (ROE)

The search engines Google Scholar and Google as well as healthcare sector electronic databases were searched to find publications. There were few studies found through common healthcare databases, probably because of the terms that are used in their indexing. For instance, Ovid Medline could not be found when searched through the search of the main search terms. Some of the search terms were hospice care, anxiety or fear, attitude to death, stress-psychological, human, death and death anxiety (Peters et al., 2013).

Reference lists from the identified studies and PubMed were the primary sources. Studies done before the year 2006 were not included so that the currency of the data could be maintained. The abstracts and paper titles were carefully examined. For those found relevant, the papers were read fully and articles selected for review. On account of several designs, methods of sampling, evidence levels, and the final results are brought forward in the form of a narrative report that is descriptive rather than in a different format, for example a meta-analysis.

All primary studies whose focus was on anxiety of death in the profession of nursing were included. Synthesis of data was done according to the guidelines outlined in the Critical Skills Appraisal Programme (Peters et al., 2013). The details of the study were arranged systematically to report the equipment used and the design, as well as extraction of results and outcomes of the study. No examination was carried out on the studies' quality considering the design variations and levels of evidence.

b) Review of the relevant articles

The viability of a Cognitive Behavioral Therapy with regards to an Insomnia (CBT-I) mediation in hospice nurses who are bereaved chronically was tested by Carter et al. (2013). A five-week study that was conducted in a non-profit central Texas hospice. Agency nurses provided care to patients and their families directly and were used as the sample for the study. It was discovered that the participants experienced sleep disturbances that ranged from mild to severe and moderate symptoms of depression. The participants accepted the CBT-I intervention well and their participation was increased by on-site delivery. Conclusions: There is need for more longitudinal study to determine the efficiency involving CBT-I interventions, and to promote self-supervision amid nurses in hospice care. This is because they might be at a higher risk of experiencing compassion stress as well as quitting hospice care as a result. This study implies that hospice nurses have exposure to chronic grief. This can lead to disturbed sleep and affect the lives of hospices negatively. CBT-I interventions seem promising in giving hospice nurses important lessons on self-care through quality sleep.

A study by LaToya & Harris (2013) aimed at understanding and expanding the knowledge that is currently available about this group's coping process. Additionally, this study looked into whether coping resources are available and adequate at the workplace. A qualitative design was used in this study where 19 nurses who are registered and practical nurses with licenses participated in focus groups. It was reported that hospice nurses used humor, social support, meditation, and prayer to cope since no formal resources were provided by the agency to help them cope with stress. Informal resources were not very favorable and did not have long-lasting effects. Through this information, organizations are challenged to look deeper into this issue and come up with coping strategies that are effective. In the future, research should focus on the identification of practices and policies that will effectively protect hospice nurses from work-related stress, thus ensuring the continuity of hospice care.

The quantitative research by Seed & Walton (2012) aimed at gaining an insight of the day-to-day challenges the nurses serving hospice patients faced and find a way to deal with the said challenges. Twelve nurses serving hospice patients that participated in the interviews in a private setting at their work place. The theory used for analyzing the data was classic and grounded. Caring for self was the main category, and had two other categories: - Dealing with the Challenges and Putting in place Ways to cope with the challenges. The Dealing with the Challenges category had three subcategories, as follows: (1) Creating Time; (2) Working with the Families, and (3) Setting clear Boundaries. The Putting in Place Ways to Cope with The Challenges category similarly had three subcategories: (1) Getting Back with Your Team, (2) Getting to an End and (3) Creating a Balance in Life. Nurses serving hospice patients encounter challenges day after day by putting in place ways of surviving and self-care. The research findings revealed that nurses were actually capable of taking necessary precaution to promote their well-being.

Edo-Gual et al. (2014) studied the experiences of nursing students, which involved dying during practice. The study used was descriptive as well as hermeneutic, and it employed semi-structured interviews (n=12) with the said students. The data acquired was analyzed by method of Colaizzi's seven-step method and managed to identify five thematic conclusions: end-of-life care training, ethics, impact, coping, and connection-healing/learning/growth. The main theme was the huge effect the death encounter caused, and other themes included a reaction to/or moderating effects. They derived a model to explain the study, based on the relationship between the themes that emerged. The conclusion was that it is important to understand the students' death experiences in order to reduce its effects.

Sacks & Volker's (2015) study intended to develop a theory that was inductive, to describe the procedure that the nurses serving hospice patients used to point out and react to the struggle their patients went through. Additionally, the study wanted to explain the overcoming strategies that the nurses serving hospice patients would use when working with patients they thought were suffering. The Grounded methodology theory led the design of the study with 22 nurses serving hospice patients taking part in the semi-structured interviews. These participants would work on their patients' pain within a 4-phase procedure of the relationship between the patient and the nurse: observing, issuing an assessment, diagnosing the suffering, and intervening. Apart from the physical anguish, participants pointed out other modes of pain: loneliness, guilt and/or regret, role maintenance failure, and fearing death. The findings of the study are used to develop working interventions to prevent the patients from suffering and reduce the severity of its effects on the nurses. When the administrators understand the strategies used by the nurses to cope with the sufferings encountered by the patients, they could come up with policies that support the specific staff, create educative programs, and build environments that support these strategies.

c) Review of standards of practice

HIPAA Privacy Rule's Section 164.514(a) offers the standard involving protected health data's de-identification. Within this rule, health data is not independently identifiable in case it does not classify an individual as well as in case the covered unit has no rational basis to consider it may be utilized to identify the individual (El Emam, 2013).

a. "Expert Determination" method

Specifications for implementation: information on health de-identification requirements. An entity that has been covered may establish that information on health cannot be identified individually as information on health only if: A person with necessary information and experience with scientific and statistical methods and principles for non-individually identifiable information rendering:

(i) Implementing such methods and principles, establishes that the chances of the information being used are small, combined with other information available or alone, by an expected recipient to expose a subject of the said information; and (ii) Writes the results and methods of the study that validates such a conclusion; or

b. "Safe Harbor" procedure.

These stated pointers of the relatives or of the individuals, employers, the individual's household members are deducted: (A) Names, (B) Subdivisions less than states, that include: city, precinct, street address, county, ZIP code, other than the first three numbers of the ZIP code if, depending on the data currently available publicly from the Census Bureau: (1) The geographic section formed when ZIP codes containing similar three initial numbers has over 20,000 people; (2) The first three numbers in a ZIP code for similar geographic units with 20,000 or less changes 000, (C) All date elements (other than year) for dates related directly to the person, including admission, birth, death, discharge, and ages beyond 89, and date elements (years included) indicating age, save for when such elements and ages could get aggregated to a class of 90 or more, (D) Vehicle, phone and serial, numbers in addition to license plates (E) Serial, device and Fax numbers, (F) Web Universal Resource Locator (URLs), Email address (G) Internet Protocol (IP) address, Social security numbers (SSN), (H) Biometric identifiers, like voice and finger prints, numbers of Medical records (I) Photographs of a full face and images that can be compared, numbers of beneficiary health plans, (J) Account numbers, unique numbers of identification, code, characteristic except those permitted in paragraph (c), and (K) numbers of license/certificate among others (El Emam, 2013).

3) Conclusion

Nursing a dying person is a highly demanding job that demands skills in nursing and makes it necessary for nurses to have personal insight about dying and death. Nurses who were positive about death mostly had a positive feeling towards giving near-death care to their patients. The nurses ought to assess their spiritual beliefs and race (and that of the patient that is dying too), since it may have an impact on their positivity when caring for a dying patient. Despite the culture of the place where the nurses work, nurses under 30 years, with a low ability to deal with negative disposition and the requirements of the emotional task would learn from education on death at their place of work.

COPING OF HOSPICE NURSES 1

COPING OF HOSPICE NURSES 11

Progressing with the project, the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) design would be in use for reviewing the nurses' strategies in coping. JHNEBP is a strong approach for finding solutions to make decisions in clinics, and is tagged along with user-friendly tools to help groups and individuals. It is specifically designed for the needs of the nurse doing practice, and it employs a process of three steps known as PET: practice question, evidence, and translation. The aim of this model is to ascertain that the most recent findings and the best exercises are swiftly incorporated into the care of the patient.