Exploring the traum a care nurse ’ s lived experiences of dealing with the violent death of their clients

A phenomenological approach was used to explore the phenomenon, violent death, from the perspective of trauma care nurses working in Kwa-Zulu Natal. Three relatively unstructured interviews were undertaken on an individual basis with each lasting thirty to forty-five minutes long. The researchers applied the principle o f theoretical satu­ ration and a total o f seven participants from three levelone trauma units were included in the study. All the inter­ views were tape recorded and transcribed, and manual analysis, as well as a qualitative software package NUD*IST was used to identify experiential themes within the data. The trauma care nurses conceptualized violent death as being sudden, unpredictable, senseless and not as digni­ fied or peaceful as a non-violent death. A number of is­ sues that made confronting violent death difficult were raised and the trauma care nurses described a number of emotional and physical reactions that they experienced due to exposure to these situations. A number of recom­ mendations were suggested for the trauma care nurses, nursing management, nurse educators and for future re­ search in an attempt to prevent the loss of these valuable nurses from the nursing profession. Abstrak ‘n Fenom enologiese benadering was benut om die verskynsel van geweldadige dood vanuit die perspektief van trauma verpleegkundiges werksaam in Kwa-Zulu Natal te ondersoek. Drie re la tie f ongestruktureerde onderhoude is op ‘n individuele basis met elke deelnemer, van ongeveer dertig tot veertig minute elk, gevoer. Die navorsers het die beginsel teoretiese versadiging toegepas en ‘n totaal van sewe deelnemers vanuit vlak een traumaeenhede was in die studie ingesluit. A1 die onderhoude is op audio band opgeneem en getranskribeer. Beide manuele analise, sowel as wel as die kwalitatiewe sagteware paket NUD*IST was gebruik om ervarings temas in die data te identifiseer. Die trauma verpleegkundige sien geweldadige dood as ‘n skielike, onvoorspelbare, sinnelose en nie so waardig of vreedsaam soos ‘n n ie-gew eldadige dood. ‘n A antal kwessies wat konfrontasie met geweldadige dood bemoeilik is deur die trauma verpleegkundiges geïdentifiseer asook ‘n aantal emosionele en fisiese reaksies wat ervaar was gedurende die blootstelling aan hierdie situasies. Ter voorkom ing van die verlies van hierdie w aardevolle verpleegkundiges vanuit die verpleegprofessie, word ‘n aan ta l aan b ev e lin g s aan traum a-verp leegkundiges,verpleegbestuurders, verpleegdosente en vir toekomstige navorsing gemaak.


Introduction
Violence is said to be the leading cause o f injury severity in South A frica and the 1996 hom icide rate of 61 per 100 000 placed South Africa among the m ost violent countries o f the world (M arais, 1998). Traum a in the province o f KwaZulu -Natal is considered to be a huge problem with violent deaths being the highest o f all causes o f death in the Durban m etro politan area. In a study carried out by M eum ann & Peden (1997) in the Durban m etropolitan area focusing on one state and one private hospital, it was found that 32.2% o f the re ported deaths were traffic -related deaths and 13.1% were said to be due to an accident. The rem aining 54.7% o f the reported deaths was due to violence -90.4% o f the victims had reportedly been assaulted and 9.6% had com m itted sui cide. A lm ost half o f the assault cases had died from firearm injury, but sharp objects (for exam ple stabs) also accounted for a significant proportion o f these deaths. Another disturb ing factor o f the results was that the average age am ongst the total 398 cases was 33.6 years (M eumann & Peden, 1997). Nationally, trauma care nurses are faced with traumatic deaths on a regular basis and added to this is the fact that the m ajor ity o f these deaths are o f young adults in the prime o f their life. It is acknowledged that the work of the trauma nurse is extrem ely stressful and can lead to burnout, acute stress dis orders or Post-Traumatic Stress Disorder. Increased aw are ness o f the influence that the constant confrontation with vio lent death has or can have on the traum a staff is o f great importance, in order to protect the staff involved.

Purpose of the research
The purpose o f the study was to explore the lived experiences of these traum a care nurses who are constantly being con fronted with the violent death o f their clients.

Operational concepts V io le nt death
The sudden and unforeseen loss o f life, which results in a body (corpse) which may be mutilated or horrible to look at. The death was not a peaceful one and in some cases, it could have been prevented (Ruby, 1998). These deaths usually took place in the trauma units or within approxim ately two hours o f handing the patient over to either critical care or theatre personnel.

Level -one traum a unit
Level-one trauma units are nationally recognized as special ized trauma units due to the fact that they adhere to specified requirements. These units have a minim um quota o f trauma qualified and/or experienced staff (both nurses and doctors) as well as specialized resources and necessary equipment avail able to deal with severely physically traumatized clients.

Trau m a care nurse
A nurse, who is recognized by the South African Nursing Council as a registered nurse, and has worked in a recog nized level-one trauma department for a minimum o f one year. The nurse may or may not have undergone further trauma or emergency care training.

Clients
The individuals who interact with the personnel working in the traum a units either as a patient, a family member or sig nificant others.
Dealing (with violent death) Being exposed to the reality of violent death and providing or involved in the emergency care rendered to the person dying, or to the patient with a high likelihood of dying due to the presenting clinical signs and symptoms. May be exposed to the body (corpse) and the significant others. It also involves managing the effects of this exposure and involvement in one's personal and working life.

Ethical considerations
Permission was obtained from the provincial authorities, as well as the board of management of the private hospital, prior to approaching the participants. The selection o f participants was done on a strictly voluntary basis and the participant's real name was not used in the interviews -the participants were asked to choose a pseudonym. The researchers attempted to establish rapport with the participants and also discussed with the participants the issue of secrets and m aintaining con fidentiality. Support was given to the participants by the re searchers due to the sensitive nature o f the phenom enon be ing explored, by allowing time for debriefing after the inter view. The researchers were aware that hospital counsellors were available and one researcher had basic M ental Health training which enabled the identification of those partici pants who might require further psychological support. The participants were informed o f their right to withdraw from the research at any time. The recordings of the interviews were only accessible to the researchers and the person help ing with the transcribing. Once the raw data from the taped interviews was imported into the com puter package all the taped interviews were destroyed. The raw files were identi fied using the pseudonyms only; thus the data could not be traced back to the participant.

Research design
A qualitative research design was chosen for this study as this is considered to be a holistic research approach, which allows the researcher to gain a full view o f the phenomenon under study. Qualitative research is also descriptive, and is an excellent way o f obtaining information and exploring a p a rtic u la r p h e n o m e n o n (P o lit & H u n g le r, 1993). A phenomenological approach was used in this qualitative re search, to explore from the perspective of the trauma care nurses themselves, their experiences o f being confronted with the violent death of their clients.

The selection of participants
Scientific purposive sampling was used as the researchers considered registered nurses working in recognized level-one trauma units, with at least one year o f working experience in the trauma departments, for inclusion in the study. This was due to the fact that the researchers wanted to include trauma care nurses who had sufficient experience of confronting vio lent deaths within the trauma unit environment. Registered nurses working in one private and two state level-one trauma units were considered for inclusion in the study.

Credibility
Credibility was obtained by prolonged engagement as the re searchers spent a great deal o f time interviewing the partici pants in the field. These interviews were conducted over a period o f time (about six months) and the researchers inter viewed all the participants. At each interview the researchers confirmed the findings from the previous interview with the participants in order to ensure that the results were in fact a true reflection o f the participants experiences (Brink, 1993). The researchers also attempted to give the reader a sense of being there and truly experiencing the research for themselves by giving in-depth descriptions o f the events. The research ers remained in the field collecting data until no new infor mation was being obtained. This is referred to as saturation and is seen as the sense o f closure that the researchers experi ence when the data collection fails to yield any new informa tion (Polit & Hungler, 1993:333). "Thick" descriptions o f the research process and o f the data provided by the participants was given, thus the researchers endeavoured to demonstrate mastery o f the chosen research method. W hen documentation was taking place the research ers were rigorous and ensured that all steps and decisions taken during the research were written down and a motiva tion was given (van der M erwe, 1996). Data was also trian gulated with relevant data from the literature. An experienced qualitative researcher monitored the relevance and appropri ateness of the categories and themes, which the researchers derived from the data. The researchers were very aware of the possibility of introducing bias and attempted at all times to guard against this (Brink, 1993).

Data collection
The researchers developed a crude outline of the key areas of the research in an attem pt to guide the interviews, although this guideline was very flexible and open to any changes that the researchers or the participants wished to make. As the research "instrum ent", the researchers used the responses o f the participants to guide the data collection, exploring for further information as needed for depth and clarity. The seven participants who volunteered were asked to participate in three individual interviews each using open-ended questions, which allow ed for the exploration o f them es and ideas expressed by the participants. T he first interview included an introduction o f the partici pant's experiences with confronting violent death as well as their conceptualization o f violent death. The second inter view was concerned with the effect that the confrontation with violent death had on the participants in their w orking and personal lives. The third interview allowed for the research ers as well as the participant to clarify any issues and ques tions which had arisen from the previous interviews, and for closure. This interview attem pted to deal with the m anage m ent o f and exploring possible strategies to prevent the nega tive effects o f being confronted with violent death.

The participants
The researchers interviewed a total o f seven trauma care nurses working at three level-one traum a units in the Durban M et ropolitan area. Eighteen interviews were conducted with an average o f tw o-and-a-half interview s per participant at two to three weekly intervals. One of the participants (JANE) chose to w ithdraw from the interview s and another participant, MARY, had only one interview due to extrem e difficulties faced by the researchers in trying to select an appropriate time to interview her. The participants were very enthusiastic re garding the research and expressed their concerns to the re searchers that there did not appear to be m uch recognition (financial or otherwise) for the difficult jo b they are doing under, w hat is usually, very trying circumstances. During the interviews the participants displayed a variety of em otions; sometimes laughing, crying or clapping their hands in order to em phasize a particular aspect. Due to the em o tional nature o f the phenom ena being explored the research ers set aside tim e at the end o f the interview to debrief the participants before they w ent back to work. Some of the par ticipants were very emotional at the end o f the interview due to the experiences they had been discussing and this time was essential to talk to them or ju st to listen. The debriefing pe riod lasted five to ten m inutes and this allowed tim e for the participants to regain their com posure before returning to their colleagues. The researchers also ensured that the room used to interview the participants was private and unoccupied for a certain length o f time. A note was put on the door inform ing people that an interview was being conducted inside, in an attem pt to prevent interruptions.
The researchers were actively involved in transcribing the taped interviews into text and found that this was an extremely tim e consum ing exercise although it was also very beneficial. It allowed the researchers to get involved with the narratives in a very active way and facilitated the immersion o f self within the text. The data was then carefully analysed manually, as w ell as by using a com puter package for the analysis o f quali tative data -N UD*IST 4 (N on-num erical Unstructured Data Indexing Searching & Theorizing). The researchers organ ized the data by identifying meaning units, which were then categorized or coded (Creswell, 1998). All data within the same category was then grouped and sub-categories as needed were developed. The researchers developed four broad cat egories namely: how the traum a care nurses conceptualise violent death, confronting the scene, dealing with the violent death o f a client and support o f the trauma care nurse. The researchers attem pted to validate the data by m oving back wards and forwards between the raw data and the categorized data in N UD*IST 4. Data documents were then compared in order to establish common as well as unique themes, and pat terns within these themes (Bum s & Grove, 1995). Silence within the text was identified by (SILENCE) and this tended to occur when the subject was too painful to dwell on or the issue was very important to the participant.
Findings and discussion C onceptualization of violent death.
The participants conceptualized a violent death as being sud den, unpredictable, unexpected and thus very difficult for the family, as well as the trauma care nurse, to deal with. This is supported by Solursh (1990) who described a traumatic death as a sudden and unanticipated event, which was out o f the control o f the client's family. The corpse o f the client was often disfigured and suggested to the participants that the death had not been peaceful or dignified. There was consensus among the participants that gunshots, stabbings, assault and m otor vehicle collisions that resulted in death, were indeed w hat constituted a violent death. The death of the client was also viewed as being senseless, as there were numerous occasions mentioned where there appeared to be no reason for the death. A non-violent death was also viewed as different from a violent death in that the death was often peaceful and dignified, and in many cases, expected by the family.

Issues th a t made confronting violent death difficu lt to deal with
The participants described for the researchers a num ber of issues that m ade confronting violent death difficult to deal with in the trauma units. Dealing with the client was viewed by the trauma care nurse as being an extrem ely difficult situation to confront, espe cially if the client was conscious and aware o f his/her im pending death. The age o f the client was also identified as a problem in that children are innocent and are not suppose to die before their parents, which then makes their premature death very difficult to accept. It is well documented in the literature that dealing with a dying child is an extrem ely dif ficult situation to cope with -both in the interaction with the client as well as the client's fam ily (Bum s & Harm, 1993;Hattingh, 1993;Coolican, 1994;Smith, 1995& Payne, Dean & Kalus, 1998. M angini, Confessore, Girard & Spadola, (1995) go further to say that repeated exposure to the death of children can have detrimental effects on the health care work ers if they do not receive adequate support. The participants m entioned a num ber of difficulties experi enced when dealing with the relatives o f the client and this compares with a study docum ented by Payne et al (1998) who showed that some o f the m ost difficult experiences faced by the traum a care nurses were ones spent with the bereaved relatives. The level o f education o f the family also posed prob lems for the trauma care nurse as THANDI described how the family could not understand the life saving treatment be ing administered to their family member, and then accused the nurses of killing their family member. "Death-telling" was expressed by the participants as being an extremely stressful situation to be involved in as the nurse was then faced with grieving, angry or disbelieving relatives that she then had to try and console, an issue supported in the literature by McQuay, Schwartz, G oldblatt & G iangrasso. (1995). Dealing with the death of a colleague or a colleague's family m em ber was seen as being extremely stressful for the trauma care nurses, and this was documented by Dietrich & Hattingh (1993) who suggested that this situation gives rise to extremely strong emotional reactions in the health professionals. The trauma care nurses also described a num ber o f situations they experienced in the trauma unit which they personally identi fied with, these brought the experiences "close to home" for them. This then made the client's death all that much harder to deal with as it was so close to the nurse's own situation (Solursh, 1990).

Em otional and physical reactions
The participants expressed that they felt guilt, sadness and anger when dealing with the client who was dead or dying a violent death and this was supported by M angini et al (1995) who explained that the trauma care nurses are not immune to feelings of helplessness and despair. The participants also described a num ber o f emotional and physical reactions that they experienced when confronted with a critical incident, that is, an extremely stressful event that has the potential to cause unusually strong emotional reac tions and can lead to the developm ent of Post Traumatic Stress Disorder (PTSD) (Stamm, 1998). Baldwin (1998) comments that the main symptoms of PTSD are intrusions, avoidance and hyper-arousal. Examples of intrusion are flashbacks and nightmares where the event is re-experienced, and a number o f the participants (JAKE, LYNN and TULIP) described these symptoms to the researchers. Baldwin (1998) concludes by suggesting the hyper-arousal is m anifested by signs o f in creased arousal such as hyper-vigilance. This was evident in a num ber o f the interviews carried out with LYNN, who dem onstrated non-verbal cues o f hyper-arousal. She also explained to the researchers that due to her work as a trauma care nurse, she was now extremely over protective of her own child, of ten to the irritation o f her husband.

Team work in confronting the scene
The trauma care nurses were of the opinion that teamwork had both a positive and a negative influence on their daily lives. Working together as a team was useful as the staff got to know each other well and were thus able to help and sup port each other. THANDI described to the researchers that "even when you are busy resuscitating with the doctors, you fin d that it's very easy resuscitating with the people that you know, because you know their lik in g ". The doctor -nurse relationship was also identified by THANDI as being a source of stress, as she felt that her numerous years o f experience in the trauma unit were never taken into account as she was not included in any decision-making. She felt that this under mined her position as a senior nurse in charge of the unit and thus impaired the functioning o f the health care team, possi bly to the detriment of their clients. Helps (1997) concluded in a study that team cohesion and interpersonal relationships with colleagues were both a source of stress and satisfaction, thus within the environment of trauma it is essential that there be good working relations and that the members of the team recognise each other's stress.
W ays of dealing with the constant presence of violent death.

D eath beliefs
The participants described for the researchers a num ber of death beliefs that they held which helped them to deal with the difficult situations they were faced with. Some of the par ticipants described their various religious beliefs and occa sions where they had been praying over the client, whereas other participants were of the opinion that the client's death was predetermined and nothing could be done to change the outcome. Caring for the dying is a particularly demanding area of nursing and it has been suggested that the personal attitudes that one holds about death and dying strongly influ ence how one lives and works . Whittle (1999) suggests that unless the health workers are able to work through their own thoughts and feelings about death and dying, they will not be able to efficiently help their cli ents.

Physical and em otional avoidance
Some of the participants described for the researchers how there were various situations that they were unable to deal with (the most common being the death o f a child) and thus avoided this situation, either physically or emotionally. Avoid ance, is viewed by Baldwin (1998), as being evident where the trauma care nurse tries to reduce the exposure to people or things that might bring on their intrusive symptoms. This use o f "avoidance" is documented in the literature by Payne et al (1998) and a review of literature by Neimeyer (1994) also indicates that health professionals with high levels of death anxiety are more likely to use 'avoiding' coping strate gies. During the interviews with MERCIA, the researchers also became aware o f the use of escapism in that the partici pant described how she would often just go home and sleep, and wake up in the morning feeling much better about the situation (Aldwin & Revenson, 1987). The unemotional nature of the trauma care nurse is well docu mented although Schwam (1998) is o f the opinion that many health workers have just learnt to control and hide their feel ings, and thus cope with difficult situations by avoiding it either physically or emotionally. M ERCIA was o f the opin ion that there was no time to do otherwise, she said; "you finish the resusc, you take o ff your gloves, wash your hands and its either your tea-time or there's fo u r patients waiting to be stitched ... there's a backlog o f work, so you ju st shake it off". Maeve (1998) also makes mention o f the use o f 'black hu m our', that is, telling jokes to boost ones courage and to make an awful situation appear silly or less real. This was again noted during the interviews by the researchers when some of the participants made jokes or laughed inappropriately while describing extremely difficult situations.
Realization of the role of the traum a care nurse It was suggested by TULIP, that in order to cope with the difficult situations it is im portant to realize that this is the nature of the work of a trauma care nurse. Payne et al (1998) is of the opinion that trauma care nurses choose to do this work because it is extremely busy, there_is a lack of routine and a variety of procedures and clients. These authors also cautions that the trauma care nurse needs to be aware o f the fact that death is indeed an unfortunate consequence of this job. JOYCE agreed with this by saying "I must always tell m yself that I am working in a place like this so I have to fa ce everything that's going to happen Possible strategies to support traum a care nurses Debriefing Some o f the participants m entioned to the researchers that talking about the traumatic incidents that they had faced, ei ther formally or informally, helped them to cope with the situ ation. Aldwin & Revenson (1987) refer to this informal de briefing as support mobilization, where the individual makes an effort to obtain information, advise and emotional support from each other. A num ber of the participants interviewed were already involved in formal debriefing programs and sug gested that this was indeed of great benefit to them as it al lowed you to get to know your colleagues better and made you realise that you were not alone. LYNN also suggested that "with regular debriefing you get it o ff instead o f harboring it, you get it o ff your chest q u icker''. Critical Incident Stress Debriefing is a process of educating and preventing the ef fects from an exposure to a critical event. It requires the for mation of a well trained team who lead the debriefing proc ess, which then aims to reduce the stress caused by an ex traordinary event (Burns & Harm, 1993). These authors are o f the opinion that debriefings are indeed helpful for the trauma care nurse to deal effectively with the different trau matic situations they find themselves involved in and in their study, eighty-two percent of their respondents confirmed this finding. R aphael, M eldrum & M cFarlane (1996) caution against believing all good of debriefing and suggest that it may increase problems, be inappropriate in time or format for some people and that it does not take the staff's past expe riences, coping processes or life stresses into account. Raphael et al (1996) does however conclude that despite debriefing being costly and potentially ineffective, it is here to stay, for now, as it does meet some real and symbolic needs o f the trauma care nurses.

Death education
Nurses who are specifically educated to meet the needs o f a dying client and his/her family are likely to reflect a positive attitude towards coping with death (Corr & Doka, 1994). In a study carried out by Tye (1993) cited in Payne et al (1998) it was discovered that 52% of the trauma care nurses involved in the study felt unprepared to deal with sudden, traumatic deaths and the distraught relatives. JO Y CE was o f the opin ion that the reason why trauma care nurses do not function well when faced with death in the unit was due to the fact that they have never been taught how to cope with the death of a client. She stressed the importance of orientating new staff to the unit and telling them about what they may face and not leaving them to cope with stressful situations on their own. Helping the families who have lost a loved one to a violent death can be challenging although by understanding their needs and keeping ones "death skills" up to date, it can be extrem ely rew arding both personally and professionally (W heeler, 1996).

Support from nursing m anagem ent
Some of the participants felt that nursing m anagement did not appear to acknowledge the fact that working in the trauma unit was stressful for the trauma care nurses, and this then added to their stress. M ERCIA felt that she was often ne glected by the nursing m anagem ent who according to her would come in during a resuscitation and say "look at all the cotton wool swabs on the flo o r !" Helps (1997) confirms this in her own study in which trauma care nurses rated an unre sponsive nursing and hospital leadership as being an impor tant source of stress. Some o f the participants suggested that just by letting the trauma care nurses know that they were appreciated for doing such a difficult job would go a long way to helping to relieve some of the stress inherent in the work. Some of the participants also mentioned that nursing man agement should monitor stress levels in the individual staff members, encourage regular vacation and be open to rotating the trauma care nurse to other departments, if possible. It was mentioned to the researchers by some of the participants that the trauma care nurse never gets to see the clients getting better and Helps (1997) confirms that seeing clients getting better was the most frequently cited source o f satisfaction for the trauma care nurses in her study.

Recom m endations
Hospital chaplains or dedicated staff to deal with the families on arriving at the hospital or to contact relatives o f the client, need to be made available, as the trauma care nurse is often too busy to attend adequately to this task. The formation of debriefing sessions in the trauma units needs to be initiated in order to assist the health professionals to deal adequately with the stressful nature of their daily work. Both o f these recommendations were already suggested in a study carried out by Kerr (1996). Nursing management needs to be aware o f the importance of allowing the staff to see clients getting better, and efforts should be made to follow up on the clients that have survived and ensure that the trauma care nurses be made aware of their 'successes'. Nursing management should also be aware that stress disorders can lead to a decrease in jo b performance, staff morale and an overall decline in the health o f the trauma care nurse. Attempts should be made to try and support the staff as much as possible by interviewing them on an indi vidual basis at regular intervals, to assess the staff members stress levels and to ascertain if the nurse has any special re quests, for example, rotation out of the unit for a short time. Nurse educators need to be made aware o f the apparent lack of death education in the current undergraduate curriculum for nurses and this needs to be addressed. Nurse educators should also acknowledge the importance of stress within the nursing profession and nursing students need to be taught ways o f recognizing their own stress levels and stress man agem ent. The social support netw orks of the traum a care nurses is o f great importance and the researchers were of the opinion that this area could be explored further. This was supported by Helps (1997) who felt that research in this area would be effective in establishing ways of managing the oc cupational stress faced by trauma care nurses. As the sample size in this research study was very small, a quantitative re search study in this area would be o f great interest in order to explore the views o f more o f the traum a care nurses and pre hospital health care professionals.

Conclusion
The role of the trauma care nurse in South Africa is challeng ing* exciting but also extrem ely stressful due to the violent deaths of a num ber o f clients in the traum a units. Presently the trauma care nurses appear to be aware of the effects that dealing with these deaths is having on them, but are unable to do much to im prove their situation. A num ber of recom mendations have been suggested by the participants as well as the researchers and one hopes that these may indeed be attem pted before the nursing profession loses these valuable professionals to the ravages o f various stress disorders.

Lim itations of the study
A limitation o f the study was the withdrawal o f a participant from the study (JANE) as well as the problems experienced in trying to interview another participant (MARY), both of these participants were then excluded from further interviews. The fact that the interviews were carried out on duty time could be argued to have influenced the interviews, as the par ticipants were aware that they could be (and often were) called to help with a client. The presence o f the researchers could have influenced the participant's responses, as all were aware that the researchers were from an educational institution, and then possibly gave the answers that they thought the research ers would like to hear. The traum a care nurses all appeared to use a particular way o f talking and describing incidents to the researchers, they all appeared to have acquired a type o f 'traum a slang'. Due to the use of this language it may prove to be quite difficult for a reader, not well versed in the trauma care field, to understand and correctly interpret what the par ticipants were saying. A further limitation o f this study was the very small sample size due to the chosen methodology, and thus the researchers are unable to generalize these re sults beyond the context o f this study.