The impact of death and dying on the personhood of senior nurses at the National Cancer Centre Singapore (NCCS): a qualitative study

Abstract

Background A nurse’s role in caring for the dying is fraught with ethical, professional, and psychosocial challenges that impact how they perceive their roles as professionals. When unsupported, nurses caring for the dying experience burnout, career dissatisfaction and leave the profession. Better understanding of how caring for the dying affects the professional identity formation (PIF) of nurses will guide efforts to better support nurses. Methods Guided by new data on the subject, we adopt the theoretical lens of the Ring Theory of Personhood (RToP) to evaluate how caring for the dying impacts the values, beliefs, principles, professional identities and personhood of nurses. We employ Krishna’s Systematic Evidence-Based Approach (SEBA) to guide the design and piloting of the semi-structured interview tool. Results Analysis of interviews with eight senior nurses in Supportive, Palliative and Oncology care revealed three domains: Identity 1) Formation; 2) Conflict and 3) Refinement. Identity Formation occurs early in a nurse’s career, upon entering a new specialist field, and at the start of Supportive, Palliative and Oncology care. Identity Formation reveals significant changes to how self-concepts of professional identities are tied to individual concepts of personhood. Caring for the dying, however, resulted in Conflicts between values, beliefs, and principles within regnant concepts of personhood and their professional duties. These conflicts are captured as conflicts within (‘disharmony’) and/or between (‘dyssynchrony’) the rings of the RToP. These conflicts can result in changes to self-concepts of personhood and professional identities. Identity Refinement sees experience and timely support helping nurses attenuate the impact of difficult experiences. This reduces the risk of burnout and mitigates changes to their professional identities. Identity Refinement helps them develop a ‘rooted identity’ which remains relatively consistent in the face of adversity. Conclusions Ongoing Identity Construction amongst nurses, particularly in caring for the dying, underscore the host organisation’s role in ensuring structured, longitudinal, accessible, and personalised assessments and support of nurses, especially when they are prone to dyssynchrony and disharmony whilst caring for the terminally ill. Further study into assessment methods and the role of the environment is critical.

Systematic scoping review on moral distress among physicians

“…Ho et al 38 Kuek et al 3 Chan and Chia40 and Huang et al 41 provide clinical evidence of these ties between self-concepts of personhood and identity using the ring theory of personhood (RToP) to study the experiences of physicians, nurses and medical students caring for terminally ill patients and confronting the death of their patients. Similarly Ho et al ’s42 study of how senior palliative care and oncology nurses at a cancer centre cope with caring for dying patients and their distress in facing the death of their patients, suggest that psychological distress akin to recent accounts of MD may be better understood through the employ of the RToP framework 3 38 40 41…”

A systematic scoping review of reflective writing in medical education

“…The Krishna Model of RW posits that the RToP is able to encapsulate various aspects of the physician’s belief system. The Innate Ring which represents the innermost ring of the four concentric rings depicting the RToP is derived from currently held spiritual, religious, theist, moral and ethical values, beliefs and principles [ 13 , 51 , 53 , 252 ]. Encapsulating the Innate Ring is the Individual Ring.…”

“…Encapsulating the Innate Ring is the Individual Ring. The Individual Ring’s belief system is derived from the physician’s thoughts, conduct, biases, narratives, personality, decision-making processes and other facets of conscious function which together inform the physician’s Individual Identity [ 13 , 51 , 53 , 252 ]. The Relational Ring is shaped by the values, beliefs and principles governing the physician’s personal and important relationships [ 13 , 51 , 53 , 252 ].…”

“…To synthesise a coherent narrative from the multiple accounts of reflective writing, we adopt Krishna’s Systematic Evidence-Based Approach (SEBA) [ 10 , 15 , 21 , 46 – 53 ]. A SEBA-guided Systematic Scoping Review (SSR in SEBA) [ 13 – 24 , 50 , 53 – 55 ] facilitates reproducible, accountable and transparent analysis of patterns, relationships and disagreements from multiple angles [ 56 ].…”

“…The SEBA process (Fig. 1 ) comprises the following elements: 1) Systematic Approach, 2) Split Approach, 3) Jigsaw Perspective, 4) Funnelling Process, 5) Analysis of data and non-data driven literature, and 6) Synthesis of SSR in SEBA [ 10 , 15 , 21 , 46 – 53 , 57 – 60 ] . Every stage was overseen by a team of experts that included medical librarians from the Yong Loo Lin School of Medicine (YLLSoM) at the National University of Singapore, and local educational experts and clinicians at YLLSoM, Duke-NUS Medical School, Assisi Hospice, Singapore General Hospital, National Cancer Centre Singapore and Palliative Care Institute Liverpool.…”