Authors: Loujain Sharif, Khalid Almutairi, Ibrahim Alnasser, Zalikha Attar, Alaa Mahsoon, Aisha Alhofaian, Budour Almutairi, Yaser Alqahtani, Afnan Tunsi, Sara Yaghmour, Fayez Bokhari, Rebecca Wright
Categories: Research, Grief, Coping, Nursing, Patient death, Saudi Arabia, Cross-sectional study, Online survey
Source: BMC Palliative Care
Authors: Loujain Sharif, Khalid Almutairi, Ibrahim Alnasser, Zalikha Attar, Alaa Mahsoon, Aisha Alhofaian, Budour Almutairi, Yaser Alqahtani, Afnan Tunsi, Sara Yaghmour, Fayez Bokhari, Rebecca Wright
Nurses often face significant emotional distress and grief when dealing with patient deaths, especially in acute hospital settings. Despite extensive literature offering guidance on nursing practices for providing optimal care to terminally ill patients and their grieving families, there is a scarcity of empirical research examining nurses’ experiences of grief following patient deaths in Middle Eastern contexts. This study aimed to assess the relationship between grief and coping strategies among nurses experiencing patient death in an acute hospital in Saudi Arabia.
A cross-sectional study was conducted using an online survey distributed to nurses at King Fahad Armed Forces Hospital in Jeddah. Data from 382 nurses were analyzed using SPSS software. Descriptive statistics, bivariate analyses, Pearson’s chi-square test, Student’s t-test, one-way ANOVA, and regression analysis were employed to examine the associations between grief levels, coping strategies, and various socio-demographic and professional characteristics.
Among the participants, 80% were aged 25–40 years, and 50% were married. Most nurses (85.4%) reported normal levels of grief. Coping strategies’ mean scores ranged from 2.60 to 5.52. Grief levels showed significant correlations with nationality, received support, and intervention type. Nurses with high or severe grief levels had significantly higher mean scores for problem-focused, emotion-focused, and avoidant coping strategies (p < 0.001). A significant positive linear correlation was found between total coping scores and total grief scores. Regression analysis indicated that 21.3% of the variance in total coping scores was explained by total grief scores.
The study highlights that while nurses employ personal coping strategies, there is a need for additional, culturally tailored support to manage grief effectively. Implementing structured support systems may enhance nurses’ coping mechanisms and overall well-being when facing patient deaths.
In addition to nurses’ responsibilities of providing physical care for end-of-life patients, they also provide care for emotional distress, enduring grief, and anxiety experienced by patients and care partners in anticipation of impending loss [1]. Nursing practice is driven by compassion, and ongoing exposure to patients’ suffering and loss, combined with high work demands, can lead to an overwhelming sense of grief among nurses [2].
Grief is a complex reaction to loss, encompassing not only the expected emotional response but also the physical, cognitive, behavioral, social, and philosophical dimensions [3]. The nature of grief cannot be confined to a single domain of origin, as grief experiences can impact individuals at psychological, sociological, and physiological levels, either individually or concurrently [3]. Factors influencing how healthcare professionals respond to patient death are inherently personal, and it has been suggested that life experiences and encounters with mortality shape the ways in which these responses are expressed and which coping strategies are used [4, 5].
Many hospital nurses, despite their expertise in advanced medical treatments and patient care, often find themselves ill-prepared to attend to patients in the final stages of life [6]. When nurses experience grief at the death of a patient in their care, they report feeling powerlessness, guilt, fear, denial, shock, anger, crying, sadness, regret, compassion, relief, helplessness, and fear of the family’s reactions [7–12]. Certain factors have been found to exacerbate the incidence of grief among nurses during patient death. These include deaths of a younger person [10, 11], duration of death (sudden/unexpected or drawn out), relationship with the patient or family, and if the patient dies without family [10, 11].
As grief is not solely an emotional process (it manifests in physical, cognitive, and psychological aspects of health), effective coping strategies are essential for resilience to the negative implications of grief. Coping involves successful stressor management. It assesses strategies employed by individuals to manage stress [13]. Coping strategies are methods employed by nurses to manage the demanding situations they encounter [14, 15]. Coping strategies can be classified as adaptive or maladaptive [16]. Adaptive coping strategies focus on addressing both problems and emotions associated with a situation, whereas maladaptive strategies revolve around avoidance [16]. Effective coping results in more positive long-term mental health outcomes and contributes to enhanced overall well-being after a significant life event [17]. Conversely, a lack of successful coping strategies is linked to a higher occurrence of persistent mental health problems, such as anxiety, depression, and post-traumatic stress disorder [18]. For nurses, various work factors can influence coping either negatively or positively, such as workload, staffing, and previous experience with death [10, 11].
Different coping strategies successfully used by nurses in response to grief over the loss of a patient include talking about the death in the workplace [10] and strong nurse-to-nurse relationships with supportive listening, moral support, and informal discussions [8, 12]. Formal support is an effective method for coping, including debriefing, clinical supervision, and counseling services [12]. Other nurse-reported coping mechanisms include relaxation techniques [10], solitary reflections, socializing, family time, exercise, and leisure pursuits [12]. In addition, beliefs about death can aid coping, normalizing it as life’s natural course, with prayer and acceptance of death as divinely ordained, providing solace in some instances [12]. Some nurses find that the act of providing nursing care and responding to others needs was in and of itself, a method of coping, for example, satisfaction in helping families grieve or ensuring successful organ donation after a patient’s death [12].
Despite a rich body of literature guiding nursing practices in providing optimal care for terminally ill patients and their grieving families [19, 20], there is limited empirical research exploring nurses’ experiences of grief after patient death in Middle Eastern contexts. The cultural contexts nurses work in is particularly important to understand as professional and personal practices and preferences will be influenced by the norms of that culture. For example, there are specific spiritual practices in Arab and Muslim cultures such as positioning a dying person towards Mecca, and belief in the power of God to heal at any stage, the latter of which has significant implications for timing and presence goals of care conversations [21]. How death and loss is subsequently understood and processed will be directly influenced by these cultural norms and as such, interventions and support must take these contexts into consideration if they are to be effective [22]. This study sought to assess the relationship between grief and coping strategies among nurses dealing with patient deaths in an acute hospital setting in Saudi Arabia.
We employed a descriptive, cross-sectional, correlational research design.
We recruited all nursing staff members who had experienced and cared for one or more patients who died at King Fahad Armed Forces Hospital in Jeddah. Nurses were recruited from intensive care units, medical, nephrology, surgical pediatric, and VIP wards. The main inclusion criterion was nurses who had experienced the death of a patient. Based on power analysis, the sample size was estimated at 304 participants, determining n = (z)2 p (1 − p)/d2 and a 6% margin of error.
We conducted a survey comprised of three sections. The first collected socio-demographic data included age, sex, nationality, marital status, years of experience, educational attainment, working unit, and number of patient deaths experienced during the previous year. The second section used the validated Grief Traits and State Scale for Nurses (GSSN) [23]. This 31-item self-report grieving measure is split into two dimensions. The first was a set of 12 items measuring grieving features (individual characteristics indicating the nurse’s current state of mind) scored on a 5-point Likert Scale. The second dimension also used a 5-point Likert Scale, which comprised 19 items that gauged nurses’ level of sadness. Present study testing of internal consistency found Cronbach’s alpha varied between 0.897 and 0.86 for all 31 items. The third section used the validated Brief Coping Orientation to Problems Experienced Inventory (Brief-COPE), with an overall Cronbach’s alpha range 0.912-0.935. This scale uses a 4-point Likert Scale to measure 28 items evaluating the ways in which individuals manage stressful life experiences, split into three problem-focused, emotion-focused, and avoidant coping. The wide definition of “coping” refers to the strategies used to lessen the distress brought on by unpleasant situations and lists a variety of coping strategies participants can select from, including planning, positive reframing, active coping, self-distraction, denial, substance abuse, behavioral disengagement, emotional support, humor, venting, acceptance, self-blame, and religion.
Ethics approval was obtained from the King Fahad Armed Forces Hospital Ethical Research Committee (Ref. no. REC 638). The principles of the Declaration of Helsinki were followed [24]. Before enrolling in the survey, participants received an electronic informed consent form, including information about the study’s purpose, inclusion, and exclusion criteria, their ability to accept or reject participation, and the anonymous nature of the online survey.
The survey was sent to the nursing staff via their professional email addresses in December 2023 and remained available until February 2024. Data collection followed an approach that our team had previously successfully used, wherein senior nursing staff supported recruitment among clinical units [25].
Data were analyzed using the IBM SPSS statistical software for Windows (version 26.0; IBM Corp., Armonk, NY, USA). Descriptive statistics (mean, standard deviation, frequency, and percentage) were used to ascertain the categorical variables. We used Pearson’s chi-square test and odds ratios to assess and measure the association between nurses’ categorical socio-demographic and professional characteristics and their grief levels. We used Student’s t-test for independent samples and one-way analysis of variance followed by a post hoc test (Tukey’s) to compare the mean values of quantitative variables (three factors of coping and total coping score) in relation to the demographic and professional characteristics of nurses, as well as the three levels of grief trait, grief state, and total grief. Pearson’s correlation was calculated to measure the relationship between the scores of the three factors, the total coping score, and the scores for grief trait, grief state, and total grief score. We conducted a simple linear regression analysis to quantify the linear relationship between the nurses’ total coping and grief scores. In this work, a p-value of ≤ 0.05 was considered statistically significant to ensure the precision of the results.
In total, 382 nurses participated, with approximately 80% aged between 25 and 40 years. Women accounted for 86.9% of participants. More than 50% of the sample were married, and 59.4% were Filipino nationals. More than 90% had a bachelor’s degree in nursing experience, and 61.8% had 1 to 10 years of nursing experience. These nurses’ working units were mostly intensive care units of different specialties (e.g., cardiac, pediatric, and neonatal) as well as emergency rooms, medical wards, surgical wards, Very Important Persons (VIP) wards, and pediatric wards. Among the 382 nurses, 342 (89.5%) experienced patient deaths during their working period, 62% had witnessed one to five patient deaths, and 14.6% had witnessed more than 10 deaths. Only 18.6% and 22.5% had received training and support, respectively, to deal with death incidents during their working period. The types of interventions these nurses engaged in included team debriefs (29.6%), psychological therapy (26.7%), and spiritual support (18.6%) (Table 1).
Table 1Distribution of socio-demographic and professional characteristics of nursesCharacteristicsNo. (%) Age groups <=258 (2.3) 25–3082 (24.0) 31–50112 (32.7) 36–4081 (23.7) 41–4519 (5.6) 46–5024 (7.0) >=5116 (4.7) Gender Male46 (13.5) Female296 (86.5) Marital status Single139 (40.6) Married188 (55.0) Divorced/Widow15 (4.4) Nationality Saudi45 (13.2) Indian79 (23.1) Filipino212 (62.0) Other6 (1.8) Level of nursing Diploma9 (2.6) Bachelor322 (94.2) Master11 (3.2) Nursing experience (in years) < 146 (13.5) 5-Jan111 (32.5) 10-Jun102 (29.8) 15-Nov55 (16.1) > 1528 (8.2) Working unit Intensive Care unit44 (12.9) Cardiac intensive care unit37 (10.8) Pediatric cardiac Intensive care unit14 (4.1) Pediatric Intensive care unit11 (3.2) Neonatal Intensive care unit44 (12.9) Emergency room49 (14.3) Medical ward58 (17.0) Nephro ward12 (3.5) Surgical ward45 (13.2) VIP ward9 (2.6) Pediatric ward17 (5.0) Other2 (0.6) How many patients died? 1 to 5212 (62.0) 6 to 1080 (23.4) > 1050 (14.6) Have received training Yes81 (23.7) No261 (76.3) Have received support Yes68 (19.9) No274 (80.1) Type of interventions Bereavement Counseling45 (13.2) One-to-One Debriefs with Team Leader or Other Leadership30 (8.8) Psychological Therapy90 (26.3) Spiritual Support63 (18.4) Team Debriefs107 (31.3) Other7 (2.0)
The level of grief trait, grief state, and total grief level among nurses facing patient death during their working period is given in (Table 2), where most nurses reported a normal level of grief trait (85.4%), grief state (85.7%), and total grief (86%). However, approximately 4% of the nurses reported severe grief.
Table 2Levels of grief trait, grief State, and total grief among nursesGrief and its componentsNo. (%) Grief Trait Normal level292 (85.4) High level35 (10.2) Severe level15 (4.4) Grief state Normal level293 (85.7) High level35 (10.2) Severe level14 (4.1) Total Grief Normal level294 (86.0) High level32 (9.4) Severe level16 (4.7)
The different components of coping mean values ranged from 2.60 to 5.52, with religion having the highest mean value. The emotion-focused coping factor had the highest mean value (24.54), followed by problem-focused coping (18.78) and avoidant coping (12.95). The mean coping score was 56.27 (Table 3).
Table 3Descriptive statistics of different components, three factors and total scores of coping among nursesComponents of Coping instrumentMinimumMaximumMeanSd. Components Self- distraction284.541.67 Active Coping285.121.79 Denial283.041.31 Substance Use282.600.96 Use of Emotional support284.191.68 Use of Instrumental support284.201.71 Behavioral Disengagement283.121.42 Venting283.671.40 Positive Reframing285.011.88 Planning284.461.74 Humor282.641.13 Acceptance285.521.76 Religion285.611.84 Factors Self-blame282.901.27 Problem Focused Coping83218.786.0 Emotion Focused Coping124824.546.13Avoidant Coping83212.953.68Total score2811256.2714.2
The association between nurses’ socio-demographic and professional characteristics and their grief levels showed a statistically significant association with nationality, received support, and intervention type. For nationality, a higher proportion (46.7%) of Saudi national nurses had a risk level of grief when facing patient deaths during their working hours, followed by 11.4% of Indian nurses and 8.5% of Filipino nurses, which showed a highly statistically significant difference (p < 0.0001). Only 5.9% of nurses who received support had an ‘at-risk’ level of grief, compared with 16.1% of nurses who did not receive support (p = 0.031). Nurses who underwent psychological therapy had a higher level of grief (24.4%), whereas 7.5% of those who underwent team debriefs had a higher level of grief (p = 0.018) (Table 4).
Table 4Association between socio-demographic & professional characteristics of nurses and level of their griefCharacteristicsGrief LevelΧ^2^-valuep-valueNormalRisk Age groups <=256 (75.0)2 (25.0)12.460.052 25–3063 (76.8)19 (23.2) 31–5097 (86.6)15 (13.4) 36–4071 (87.7)10 (12.3) 41–4518 (94.7)1 (5.3) 46–5023 (95.8)1 (4.2) >=5116 (100.0)0 (0.0) Gender Male39 (84.8)7 (15.2)0.060.804 Female255 (86.1)41 (13.9) Marital status Single120 (86.3)19 (13.7)2.770.251 Married159 (84.6)29 (15.4) Divorced/Widow15 (100.0)0 (0.0) Nationality Saudi24 (53.3)21 (46.7)46.55< 0.0001 Indian70 (88.6)9 (11.4) Filipino194 (91.5)18 (8.5) Other6 (100.0)0 (0.0) Level of nursing Diploma6 (66.7)3 (33.3)3.060.217 Bachelor279 (86.6)43 (13.4) Master9 (81.8)2 (18.2) Nursing experience (in years) < 138 (82.6)8 (17.4)5.960.202 5-Jan92 (82.9)19 (17.1) 10-Jun88 (86.3)14 (13.7) 15-Nov48 (87.3)7 (12.7) > 1528 (100.0)0 (0.0) Working unit Intensive Care unit40 (90.9)4 (9.1)8.790.642 Cardiac intensive care unit32 (86.5)5 (13.5) Pediatric cardiac Intensive care unit13 (92.9)1 (7.1) Pediatric Intensive care unit9 (81.8)2 (18.2) Neonatal Intensive care unit38 (86.4)6 (13.6) Emergency room42 (85.7)7 (14.3) Medical ward50 (86.2)8 (13.8) Nephro ward11 (91.7)1 (8.3) Surgical ward38 (84.4)7 (15.6) VIP ward8 (88.9)1 (11.1) Pediatric ward11 (64.7)6 (35.3) Other2 (100.0)0 How many patients 1 to 5181 (85.4)31 (14.6)0.80.671 6 to 1068 (85.0)12 (15.0) > 1045 (90.0)5 (10.0) Have received training Yes70 (86.4)11 (13.6)0.020.893 No224 (85.8)37 (14.2) Have received support Yes64 (94.1)4 (5.9)4.680.031 No230 (83.9)44 (16.1) Type of interventions Bereavement Counseling40 (88.9)5 (11.1)13.620.018 One-to-One Debriefs with Team Leader or Other Leadership25 (83.3)5 (16.7) Psychological Therapy68 (75.6)22 (24.4) Spiritual Support55 (87.3)8 (12.7) Team Debriefs99 (92.5)8 (7.5) Other7 (100.0)0 (0.0)
The comparison of the mean values of the three coping factors (problem-focused coping, emotion-focused coping, and avoidant coping) and the total coping score in relation to the nurses’ socio-demographic and professional characteristics showed a statistically significant difference in relation to nurses’ working units. The mean values of the three factors and the total scores were significantly higher among nurses working in the pediatric ward (Table 5).
Table 5Mean values of three factors and total score of Cope instrument based on socio-demographic & professional characteristicsCharacteristicsProblem Focused CopingEmotion Focused CopingAvoidant CopingCoping total scoreMean (Sd.)p-valueMean (Sd.)p-valueMean (Sd.)p-valueMean (Sd.)p-value Age groups <=2519.75 (3.9)0.45426.50 (3.5)0.7214.88 (3.0)0.15361.12 (5.6)0.727 25–3018.09 (5.6)24.87 (6.4)13.74 (3.8)56.69 (14.4) 31–5019.17 (6.1)24.35 (5.8)12.47 (3.3)55.99 (13.7) 36–4018.26 (6.2)24.16 (6.5)12.85 (4.2)55.27 (15.5) 41–4520.89 (5.4)26.21 (3.6)12.63 (3.0)59.73 (10.1) 46–5018.17 (7.0)23.42 (6.9)12.17 (3.2)53.75 (15.6) >=5120.19 (7.1)24.75 (7.1)13.38 (3.7)58.31 (16.4) Gender Male20.15 (5.5)0.09925.46 (5.9)0.27413.67 (4.7)0.15459.28 (14.7)0.123 Female18.57 (6.1)24.39 (6.1)12.84 (3.5)55.80 (14.1) Marital status Single18.93 (5.9)0.30624.88 (5.9)0.55312.84 (3.5)0.77356.65 (13.6)0.52 Married18.50 (6.2)24.22 (6.4)12.99 (3.9)55.71 (14.9) Divorced/Widow20.93 (5.4)25.33 (4.2)13.53 (2.1)59.80 (10.0) Nationality Saudi18.22 (5.1)0.00126.00 (6.0)0.09414.20 (3.3)0.00558.42 (12.6)0.198 Indian17.13 (5.6)23.24 (6.4)13.70 (3.9)54.06 (15.0) Filipino19.67 (6.3)24.73 (6.1)12.44 (3.6)56.83 (14.3) Other13.50 (4.2)23.83 (2.8)12.00 (3.3)49.33 (9.3) Level of nursing Diploma19.89 (6.9)0.67526.11 (3.7)0.30513.67 (3.2)0.16459.66 (11.7)0.316 Bachelor18.71 (6.0)24.41 (6.1)12.87 (3.5)55.98 (14.0) Master20.00 (6.7)26.91 (8.2)14.91 (6.6)61.81 (20.7) Nursing experience (in years) < 119.46 (4.8)0.43225.17 (4.9)0.24713.37 (3.7)0.39558.00 (11.3)0.279 5-Jan19.23 (5.9)25.32 (6.2)13.33 (3.6)57.89 (14.1) 10-Jun18.19 (6.4)23.79 (6.5)12.81 (3.9)54.79 (15.3) 15-Nov17.95 (6.5)23.55 (6.0)12.25 (3.3)53.74 (14.2) > 1519.68 (6.1)25.00 (6.6)12.64 (3.9)57.32 (14.7) Working unit Intensive Care unit17.14 (5.5)0.03423.34 (5.6)0.01812.18 (2.8)0.0352.65 (12.5)0.016 Cardiac intensive care unit18.97 (5.4)24.86 (6.1)13.81 (4.5)57.64 (14.5) Pediatric cardiac Intensive care unit17.71 (4.6)23.79 (4.3)10.86 (2.7)52.35 (9.3) Pediatric Intensive care unit18.27 (4.7)26.09 (3.4)13.18 (3.1)57.54 (8.9) Neonatal Intensive care unit20.36 (6.5)24.98 (6.0)12.89 (3.3)58.22 (14.1) Emergency room19.12 (6.3)25.33 (7.0)13.71 (4.7)58.16 (16.6) Medical ward18.17 (6.5)23.24 (5.8)12.81 (3.4)54.22 (14.3) Nephro ward20.17 (5.9)24.00 (5.6)13.00 (2.5)57.16 (12.0) Surgical ward18.27 (5.9)24.40 (6.6)12.69 (3.5)55.35 (14.2) VIP ward15.22 (6.1)20.89 (7.6)10.33 (1.3)46.44 (14.5) Pediatric ward22.06 (6.2)29.76 (4.4)15.00 (4.0)66.82 (12.7) Other27.50 (3.5)28.00 (0.0)14.50 (0.71)70.00 (4.2) How many patients 1 to 518.89 (6.1)0.62924.65 (6.4)0.913.00 (3.8)0.67756.52 (14.6)0.734 6 to 1018.98 (6.0)24.43 (5.8)13.10 (3.7)56.50 (13.8) > 1018.02 (5.9)24.24 (5.7)12.54 (3.3)54.80 (13.3) Have received training Yes18.23 (5.9)0.35424.23 (6.4)0.61413.54 (4.0)0.09956.01 (15.0)0.853 No18.95 (6.1)24.63 (6.1)12.77 (3.6)56.35 (14.0) Have received support Yes19.59 (6.4)0.22125.28 (6.0)0.26413.38 (3.6)0.28458.25 (14.2)0.201 No18.58 (5.9)24.35 (6.2)12.85 (3.7)55.77 (14.2) Type of interventions Bereavement Counseling20.09 (6.8)0.44925.11 (6.8)0.83512.51 (4.2)0.51857.71 (16.2)0.82 One-to-One Debriefs with Team Leader or Other Leadership20.07 (5.5)25.73 (5.4)13.20 (4.0)59.00 (13.5) Psychological Therapy18.22 (5.6)24.26 (5.7)13.44 (3.3)55.92 (12.9) Spiritual Support18.24 (6.5)24.24 (7.2)13.02 (4.1)55.49 (16.5) Team Debriefs18.65 (5.9)24.32 (5.7)12.55 (3.3)55.52 (13.2) Other18.86 (5.9)25.29 (6.8)14.00 (4.6)58.14 (16.3)
The relationships between the levels of grief trait, grief state, and total grief and their coping factors and total score mean values showed a highly statistically significant difference. The mean values of the three factors (problem-focused coping, emotion-focused coping, and avoidant coping) and the total coping score were significantly higher (p < 0.001) among nurses who had a high or severe level of grief trait, grief state, and total grief when compared to nurses with normal level of grief trait, grief state, and total grief (Table 6).
Table 6Relationship between levels of grief trait, grief state and total grief and their coping factors and total scoresGrief and its componentsProblem Focused CopingEmotion Focused CopingAvoidant CopingCoping total scoreMean (Sd.)p-valueMean (Sd.)p-valueMean (Sd.)p-valueMean (Sd.)p-value Grief Trait Normal level18.33 (6.1)0.00123.92 (5.9)< 0.000112.42 (3.3)< 0.000154.67 (13.8)< 0.0001 High level22.17 (5.2)28.03 (5.6)15.69 (3.8)65.88 (12.5) Severe level19.67 (4.9)28.40 (6.7)16.93 (5.0)65.0 (15.8) Grief State Normal level18.29 (6.1)0.00123.86 (5.9)< 0.000112.44 (3.4)< 0.000154.58 (13.8)< 0.0001 High level21.54 (5.2)28.14 (5.3)15.83 (3.3)65.51 (11.2) Severe level22.14 (5.6)29.71 (6.9)16.57 (5.2)68.43 (16.4) Total Grief Normal level18.30 (6.1)0.00123.87 (5.9)< 0.000112.38 (3.3)< 0.000154.55 (13.7)< 0.0001 High level22.0 (4.5)28.10 (5.6)16.22 (3.8)66.31 (11.5) Severe level21.25 (5.9)29.69 (6.8)16.88 (5.1)67.81 (16.3)
Correlation analysis showed a positive statistically significant linear correlation between the scores of the three coping factors (problem-focused, emotion-focused, and avoidant coping) and the total coping scores and grief trait, grief state, and total grief scores. That is, as the scores on the three factors and nurses’ total coping scores increased, their grief, grief, and total grief scores also increased, and all the correlation coefficients were statistically significant (Table 7).
Table 7Correlation between three factors and total scores of nurses coping and their grief scores Coping
Factors Grief trait scoreGrief State scoreGrief total scorer- valuep-valuer- valuep-valuer- valuep-valueProblem Focused Coping0.257< 0.00010.339< 0.00010.331< 0.0001Emotion Focused Coping0.352< 0.00010.433< 0.00010.432< 0.0001Avoidant Coping0.479< 0.00010.486< 0.00010.521< 0.0001Coping total score0.385< 0.00010.456< 0.00010.462< 0.0001
The regression analysis revealed that 21.3% of the changes in total coping scores among nurses were explained by the values of the total grief score, which was statistically significant (F = 92.18, p < 0.0001) with R^2^ = 0.213. The regression coefficient of the total grief score (0.411, t = 9.601, p < 0.0001) explained that for every unit change in the total grief score, the total average coping score increased by 0.411 units.
This study assessed the relationship between grief and coping strategies among nurses dealing with patient deaths, revealing that nurses experiencing higher levels of grief tend to employ more coping strategies, suggesting a complex interplay between these two factors in the context of patient care, which is consistent with a systematic review of qualitative studies conducted by Zheng et al. [26], highlighting the challenges nurses face in coping with patient deaths and identifying similar areas that should be addressed to better help nurses cope with patient loss [26]. Our study adds nuances by examining specific coping strategies employed by nurses and their associations with grief levels.
We found significant associations among socio-demographic factors, professional characteristics, and grief levels. Socio-demographics included nationality (Saudis compared to expatriate nurses), received support, intervention type (psychological therapy), and place of employment (nurses working in pediatric units). In terms of nationality, Saudi nurses were at a higher risk for grief than nurses of other nationalities. Similar findings were reported by Sharif et al. [25], who examined the relationship between psychological symptoms and job satisfaction among nurses in Saudi Arabia, which showed higher levels of anxiety and depression among Saudi nurses. This finding could be explained by the socio-cultural diversity of death and dying and suggests a possible correlation between caring for people of the same nationality and increased grief level, which has not been fully explored in the literature and requires further study. Our sample was not sufficient to explore the relationship between grief and acceptance levels among male and female nurses or across different age groups. However, in other studies, older and male nurses showed less grief and higher acceptance of patient deaths than their female and younger peers [9, 10].
Received support was of particular significance in this study, where the risk of grief was significantly higher among nurses who did not receive support compared to those who did. This finding is consistent with those of Chang [27], who highlighted the positive impact of social support from peers and supervisors on nurses providing care to terminally ill patients and experiencing patients’ deaths. Nurses’ grief risk was further impacted by the department in which they worked. We found that nurses working in pediatric departments had a higher grief risk compared to those in other departments, which could be attributed to the strong emotions triggered by observing a patient die at a young age, as echoed in many studies in the literature [28, 29]. However, a study conducted by Das et al. [30] suggested that emotional connections with patients influence grief, irrespective of setting.
The linear relationship between grief and coping identified in this study suggests that nurses employ more coping strategies as their grief levels increase. This finding contrasts with the literature, indicating that increased grief leads to burnout and reduced productivity [31]. Our findings may be attributed to the role of religion, which emerged as the most commonly used coping strategy, providing comfort and meaning during times of loss. Many nurses found solace and strength in their faith through prayers, religious rituals, and faith-based support systems. The reliance on religious coping mechanisms is consistent with the findings of Ross et al. [32], who noted that healthcare professionals frequently draw on spiritual beliefs to manage stress and grief. The spiritual dimension provides a framework for understanding and processing loss, offering a sense of purpose and hope in challenging circumstances. Integrating spiritual support into workplace interventions could enhance nurses’ emotional resilience, particularly in culturally diverse settings where religion plays a pivotal role in daily life.
Cultural background, societal norms, and personal beliefs about death and dying influence emotional responses and coping mechanisms. Studies have shown that culturally tailored interventions can significantly enhance coping strategies and mental health outcomes for healthcare professionals [33, 34]. In cultures that emphasize community support and collective grieving, nurses may find it easier to share their feelings and receive emotional support. The relevance of these interventions is particularly relevant in Saudi Arabia, where cultural and religious beliefs heavily influence perceptions of death and the grieving process [35].
Based on our findings, we recommend the development of evidence-based interventions tailored to the unique needs of nurses dealing with patient death. These interventions should operate at both the individual and organizational levels, focusing on fostering resilience and promoting mental health awareness in healthcare settings. However, further exploration is needed, specifically identifying effective modalities of support, such as counseling, peer support groups, and stress management training. Furthermore, consideration is needed regarding the timing, cultural accessibility, and different experiences across different hospital wards or units.
The study benefits from being adequately powered within a robust research design and a diverse sample. However, we did not capture any open-text responses that may have provided beneficial contextual nuances and insights which represents an important consideration for future studies. Additionally, the study’s focus on a single medical center may limit the generalizability of the findings, and future research should include multisite and multicultural exploration to provide a more comprehensive understanding.
This study explored the complex relationship between grief and coping in the context of patient death among nurses at a Saudi Arabian hospital. Our findings highlight the need to identify factors influencing nurses’ experiences of grief and coping and to provide support systems for nurses dealing with patient death, enhancing nurses’ well-being and improving patient care outcomes. Further research is needed to tailor interventions effectively, ensuring that nurses are better supported in managing their grief and promoting their overall well-being in the workplace.