Introduction

Nurses spend most of their time with patients. Work experiences gather various stories that contain a range of emotions, such as happiness, sadness, and anger. These stories are important from the perspective of the fundamentals of nursing. Stories are the formation of experiences that add meaning to life, raise awareness, and guide people. Professional nurses also use memories to guide new colleagues (1,2).

Nurses express their emotions through stories. An in-depth analysis of the stories experienced in literature reveals the patient-nurse relationship. Awareness of the feelings, burnout, human love, resentments, and empathy experienced by the nurse becomes hidden in the stories. By analyzing the stories, nurses’ feelings, understanding of the patient, and importance of mutual communication can be understood and enhanced, which improved not only the nurses’ quality of life and satisfaction but also their services (3).

This narrative investigation aimed to inspect the experience of nurses in practice in several hospitals in Palestine and compare them with those of doctorate nursing students in Turkey. Many quantitative studies have been performed on various quantitative aspects such as job satisfaction and perceived stress (4-7). However, only a few studies have focused on key areas from the perspectives of nurses. In this study, the actuality of practice, as detailed by nurses’ expression is explored.

Background

The researchers undertook an elaborate review of quantitative and qualitative studies. However, a comprehensive synopsis is beyond the scope of this paper. Since the information used in this article was nurses’ exact descriptions, the literature review for this paper was limited to qualitative studies and theoretical studies from the perspectives of nurses.

Some studies have examined nurses’ attitudes toward unforgettable events, such as those leading to deaths in Turkey and Palestine. Cevik and Kav (8) examined the attitudes of nurses toward taking care of patients in their last days through a cross-sectional study in Turkey and found that 82% of the nurses interviewed were not comfortable talking about death and had a less positive attitude toward the care of patients who were dying. The researchers argued that the lack of education and experience were the causes of this attitude. They proposed that nurses should be provided with more chances to talk about their experiences and personal feelings about death. They also recommended that more educational programs be tailored so that nurses can comprehend their attitudes toward death, overcome fear, enhance communication, and bolster their coping strategies (8).

A similar study also investigated the attitudes of nursing students toward providing palliative care in Palestine. Abu-El-Noor and Abu-El-Noor (9) conducted a cross-sectional study involving graduating nursing students at the Gaza University (n=141). The findings demonstrated that nursing students had a negative attitude toward taking care of the sick and their families at the terminal phase. They suggested that theoretical education should emphasize palliative care to refine the quality of care at the terminal stage (9).

The rationale for the high nurse turnover, leading to a shortage of nurses, has also been explored. Gök and Kocaman (10) conducted a descriptive study among nurses (n=134) to investigate the phenomenon and found that negative public opinion and adverse working conditions were the main reasons that nurses left the profession, opting to take other careers such as teaching. They suggested improving the nurses’ working conditions and addressing the problem in a multidimensional approach (10).

Several studies have highlighted the challenges that nurses undergo in Palestine. Manenti et al. (11) noted that attacks against health care providers and patients were a rising challenge. They detailed an instance where a hospital was attacked, and the attackers searched for individual patients. The increased violence in the area has also led to anxiety, depression, and psychological distress among nurses and the patient population (11).

In summary, the literature suggests that nursing students in Turkey and Palestine harbor negative attitudes toward providing palliative care to a patient, and the lack of experience and education could be one of the reasons. Since some of the study participants are highly educated nurses (PhD students), the findings may help account for the role of education and experience in nurse’s perspectives. Moreover, nurses in Turkey and Palestine encounter several challenges, such as negative public opinion, increased violence toward health care providers, depression, and psychological distresses. Thus, this study aimed to examine these concepts from the nurses’ narratives. If the challenges are solved, nurses’ quality of life and satisfaction will improve, enabling them to offer optimum care to patients.

Methods

This narrative study was based on the rational perspectives of Miller and Salkind (12), Sönmez and Alacapınar (13).The researchers undertook an elaborate review of quantitative and qualitative studies. A purposive sample of Seven doctoral students in nursing were interviewed in the qualitative scientific research course for the second semester of the year (2018-2019) at Ankara Yıldırım Beyazıt University in Turkey in 4 months. By contrast, 10 nurses from different departments working in Palestinian hospitals were interviewed in 5 months. The 17 stories generated 31,657 words for analysis.

Nurses were approached using a network sampling method and invited to give their narratives. The inclusion criteria were as follows: (a) should have worked in a hospital for a minimum of 5 years (the period needed to be competent and knowledgeable on a particular subject), (b) willing to narrate their experiences to the researcher for an hour, (c) and is a licensed and registered nurse. This inclusion criterion was adapted from Gunther and Thomas (14). After explaining the purpose of the study and obtaining written permission, a 45-60 min period was allotted for each participant to narrate their experience.

The narrative was a personal, in-depth, non-directive type. The researcher asked the participants to “elaborate on an unforgettable instance that you gave nursing care to a patient.” The researcher only interrupted to seek clarification during the narration. Consistent with the guidelines on narrative studies, no list of questions or prespecified agenda were utilized (15). Some of the stories were audiotaped and then transcribed verbatim. Participants’ identities and whereabouts were altered to maintain confidentiality. The researchers engaged in bracketing of stories to evaluate formed ideas concerning potential research findings.

The sample from Palestine was distributed in a range of clinical areas: gynecology (Gyn, n=3), medical-surgical [(MS), n=1], pediatrics [(PD), n=2], oncology [(ONC), n=1], intensive care [(ICU), n=1], and emergency department [(ED), n=2]. Demographic information was obtained from each participant. The sample from Turkey was also distributed in a range of clinical areas: Gyn, (n=1); MS, (n=1); PD, (n=1); ONC, (n=1); ICU, (n=2); and ED, (n=1), but all of them were PhD students. Demographic information was obtained from each participant (mean age, 42; range, 23-60 years). Moreover, 59 percent of the participants were of Arabic (Palestinian) origin, and others were from Ankara Yıldırım Beyazıt University and were PhD nursing students and (Turkish). The educational levels for both samples were as follows: 10%, diploma; 34%, bachelor of science in nursing; 15%, master of science in nursing; and 41%, PhD students.

The data analysis comprised the identification of the figural (predominant) themes, which came out clearly from the narratives. The researchers signed agreements of confidentiality before working on the transcripts. About half of the printed versions were read between the researchers and categorized into appropriate themes during the data analysis period. The examined data mainly came from the interview transcriptions. The researchers obtained additional data from a reflexive journal and personal notes. During data analysis, themes were derived at both latent and manifest levels (13,14). As noted by Squire (14), when carrying out a narrative study, data analysis can take an inductive or deductive thematic analysis. For this study, both approaches were utilized. Deductively, the researcher, observing the directions provided in theory-based thematic analysis, analyzed the meaning making of nurses’ experiences premised on predetermined themes (14). Themes were based on Schachter-Singer’s (1962) two-factor theory, which argues that emotion is based on two factors: cognitive label and psychological arousal. Inductively, the study also allowed for the emergence of new themes (16).

The researchers performed all interviews and completed all transcription works before data analysis to prevent the imposition of meaning from one interview to the next. The data analysis process started with the creation of a profile for every nurse to present each of them in context. The demographic data of all 17 participants were put together using a descriptive statistical format. The 17 stories generated 31,657 words for analysis. As noted, additional data came from the researcher’s notes and reflexive journals.

Findings

The majority of the participants did not have a problem with responding to the question, “elaborate on an unforgettable instance that you gave nursing care to a patient”. Moreover, the themes were similar across the two populations. Their responses were instant, thorough, and intense. Only one of the nurses was unable to concentrate on a particular unforgettable patients and events, instead of detailing a “typical” day or the technical aspects of the job. A table of themes and subthemes is presented in the appendix. Seven themes were identified as figural across clinical specialties: 1) Patient’s final moments are difficult, 2) cases involving children, 3) violence and troublesome patients, 4) unforgettable events, 5) intricacies, 6) interrogative, 7) individual and teamwork.

Patient’s Final Moments are Difficult

A significant number of unforgettable events took place when the patient was dying, and these experiences were reported by nurses from Turkey and Palestine. In some instances, the nurses felt helpless since they could not do anything to save the patient’s life. Science had been tested to its limit. For example, one of the nurses noted, “We were using the latest devices and giving the heaviest drugs, whatever the technology of our country requires.” The family also has the most profound connection and wants to be informed about their patient’s condition at each moment. However, the nurse is not always at the bedside since the time of death is usually unpredictable, and the family cannot be present at all times. One of the respondents working in the intensive care unit noted the following about the final moments, “What is difficult is to inform the family about a patient who will be dying soon. This is probably the most difficult moment for us health professionals. If you work in intensive care, you cannot escape at least once a day.”

Although the nurses are almost always available at the end time, feelings of loneliness abide. For instance, a critical care nurse noted, “My primary objective was letting him know that he was not dying alone,” which illustrates the lonely feeling of the patient at that moment. The feeling of sadness in this phase is stronger when the nurse has a long-term attachment to the patient.

Cases Involving Children

Cases that involved children were also among the most heartfelt of all 17 scenarios. Children were presented as innocent, and their suffering attracted the attention of everyone, not just the nurses. For example, one of the nurses narrated about a child who had been diagnosed with cerebral palsy, and the mother was to give an oral aspiration. However, she appeared psychologically tired and dramatically pushed the catheter down the child’s mouth. The nurse noted that cases of psychologically tired mothers and caregivers were common, especially those involving children.

Cases involving children, especially at birth, were also among the unforgettable moments. These instances are usually characterized by higher death rates, and death was noted as one of the key themes. For example, one of the nurses at the neonatal department said, “Sometimes things go wrong. The hardest part of this is that the beings who are so hasty to come to the world leave so quickly.” The nurse and caregivers are usually involved in a deep emotional connection with the child. One of the nurses detailed how parents would touch the child affectionately each time they came to visit. When the child died, the nurse was sent to a deep emotional turmoil wondering what she would tell the parents when they came to visit.

Violence and Troublesome Patients

Cases of violence in the health care setting were narrated by several nurses, particularly from Palestine hospitals. Some of them involved patients who wanted to wreak havoc and did not need treatment. One of the nurses at the ED said of the frequency with which they experience these cases, “We often encounter this situation and have no difficulty in understanding the true intentions of these patients.” The nurses had to be cunning enough to deal with these types of patients.

Moreover, violence in the form of attacks on the hospital personnel was rampant. This was a significant case with Palestinian nurses. One of them narrated how their hospital was attacked by the Israeli army in broad daylight. She said, “They had clothes that resembled those of the army. All operations stopped for four hours as they searched the hospital for a certain patient whom they did not found.” One of the pediatric nurses also noted, “One day, we were surrounded by the Israeli army. We did not have any help. We thought we were going to die. I have heard several of such cases in the Palestine border before.” One of the nurses narrated how their hospital was attacked by an armed militia. These instances left most of the nurses feeling unsafe. Moreover, no action was taken to beef up security following such incidents. Noteworthy, there were no reported cases of violence by nurses in Turkey.

Some nurses from both countries especially those who worked in ICU, MS units, and OB-Gyn departments showed that if their colleagues or doctors fail to respect them or their insights, the outcome of which is the death of the patients, and they consider this as a type of abuse and violence toward them. Moreover, the respondents mentioned the need for better collaboration among healthcare professionals so that the views of each are integrated into decision making especially in ICU and MS units.

Unforgettable Events

As the respondents gave narratives of exceptional occurrences, they extensively made use of the phases “frequently remarkable” or “I will always remember.” These narratives were given in explicit detail. They are mostly similar to a change-of-shift report, generating evaluative information from various systems. Many participants started their tales by explaining an ordinary daily operation. As one emergency nurse stated, “Many things happen daily; it’s a routine, but one stands out in mind.” A nurse from the oncology department stated, “Each day you come across many patients; they all look similar, and few things remain in your memory.” The patient’s first sight appeared to foretell the future: “I was in my normal routine in the ED and came across this man shouting and some people restraining him against the bed, attempting to have him intubated. I was like, “It will be a terrible and hard day.” Another nurse noted, “I mean, imminent disaster was all over his face. It was….one of those instances that I could feel everything was not correct.”

Sensational occurrences were uttermost cases of the unprecedented disgust of burns, maimed bodies, and inexplicable wounds. One nurse (ED nurse) noted, “Well, in the emergency department some of the most terrible incidences stick to your memory.” A nurse said that a particular client was “separated from one region down to the knee because of a very severe car accident.”

Despite heroic efforts by the nurses, many of the stories ended with the patient’s death. The losses had a strong emotional effect on the nurses, especially when the nurse appeared helpless at preventing the client’s looming demise. However, as an oncology nurse noted, “I’m not shedding tears all the time,” and these experiences were reported by nurses from Turkey and Palestine.

Intricacies

Save for a few hilarious vignettes, occurrences detailed by the nurses proved to be tragic and catastrophic, finding them unrehearsed, and giving them a chance to contemplate vagueness, “You could not find the solution…I always wonder what happened.” For instance, one nurse said about sudden death by cardiac arrest, “He did not smoke. He did not abuse drugs. He was a physically fit young lad whom I knew many things were going on for him. Why did this impediment occur to him? We will never find out anyway.”

One of the means of surviving is attempting to comprehend what transpired and the reason behind it. Retroactive mirroring on providing care to patients appeared to be centered at creating sense from unfathomable incidents. The nurses appeared to be trying to deal with the uncertain outcomes of care and their distress by deriving “lessons” that, to some extent, influenced their practice. An ED nurse reflected, “Neither of our clinical expertise could rescue her. The things I gleaned from the situation were the vitality of acting promptly and the essence of cooperation from all team members.” Even the mysterious recoveries inspired the search for meaning, “I mean, she began gaining a little bit of kidney function back, which was sort of wonderful” (MS nurse).

Interrogative

Despite knowing “what and why,” nurses often imagined if they could have taken another action to divert the result. One nurse remembered a client who passed out suddenly while she was taking her lunch break, “You let go of the traumatizing event, and you wonder. “What different action could I have undertaken?” …liable, liable! You know, what did I do?” Moreover, the participants from Turkey and Palestine often wondered about their inaction and action, as one nurse said, “I mean, if I had tipped the ER doctor and said, “You, I almost have a code, could you rush and intubate my patient?” that gentleman might have been well and alive.”

Individual and Teamwork

The loneliness of a nurse providing care was explicit in several of the narratives, as the nurses detailed their experiences of working single-handedly contrary to the odds. An ED attendant revealed why she shifted from the ICU, “Quite often, I felt like we were alone. In the ICU where I worked daily, many of the caregivers had a burnout, and they did not discern it. They did not want to be helped. They were reluctant to rise and assist other people and provide care for the sick since they were just tired with it all.” Nurses from both countries revealed that, sometimes, “The nurse is needed to take an uncomfortable procedure that the nurse thinks and may cause more bad than good to a patient with very poor outcomes for survival, and all of this raises tension, confusion, and conscientiousness during personal work and isolation.”

Some nurses from both countries, particularly those who worked in close departments, had a belief that their colleagues shared a friendship that made work enjoyable and held them from quitting the career. Indeed, one of the ED nurses stated, “…but to have the entire team at that instance, it aided in pulling each other through the crisis period. To make things moving for that client.” Nurses who formed friendships with colleagues gained from assistance.

Discussion

This narrative study aimed at understanding the experiences of nurses during extraordinary and unforgettable events. The stories were described in complete detail. Albeit the majority of stories ending in death, some were miraculous recoveries. The participants experienced the boundaries of science.

The retrospective descriptions involved questioning what could have been done better or hopelessness in finding out what transpired. The participants experienced the boundaries of science and delved into the sphere of experiential questioning, for which there are no definite responses. The theme of individual and teamwork spouses isolation or distress, a feeling often encountered by the nurses and their association (or lack thereof) with physicians, coworkers, and patients during exceptional events. The participants also detailed lessons they learned from the events and how they influenced their practice. These residues of moral distress can impede a nurse’s ability to provide care.

Death is an unavoidable event, which brings with it some of the strongest feelings. Most of the nurses experienced intense feelings of sadness and helplessness during the patient’s death. Rodgers et al. (17) investigated the effect of bathing and honoring practice on nurses and families at the time of patient’s death and found that they had a positive influence and eased the grieving process. Thus, bathing, dressing, and honoring practices need to be introduced to reduce the feelings that come with death for both nurses and family, in addition to the need for a more systematic debriefing for both of them (17). Zheng et al. (18) investigated the effect of systematic debriefing on nurses, and the results of this systematic review could provide evidence for nurses’ coping approaches when dealing with patient death, and the recommendations could be employed by nurses to deal with the losses of patients and in cases of complicated conditions.

The findings are also in line with the results of several studies. Cevik and Kav (8) noted that a lack of education might be the critical reason for nurses’ negative perspectives on caring for patients at their end times. In this study, although the events surrounding the end of life were traumatizing at times, nurses did not harbor negative attitudes toward care provision. They did their best and examined methods that could have handled the situation better even after the patient was dead. Since some of the participants were PhD students and had more than 5 years of experience in the nursing profession, the researcher concludes that education level and experience are vital in forming positive attitudes toward extraordinary events in nursing (8). Moreover, Leana et al. (19) found that being empathetic as a nurse led to positive outcomes of treatment. Kelo et al. (20) argued that more training and administrative procedures for nurses are needed to enhance the quality of empowerment education they provide to children and families. Thus, nurses with a lower level of knowledge should be exposed to experiences and training that enhance positive attitudes and empathy at the time of death.

Besides, the finding that nurses in both Turkey and Palestine, especially in the ICU and ED, often experience burnouts, stress, and sadness are consistent with other findings in the literature. Manenti et al. (11) noted that Palestinian nurses faced physical distress, depression, and sadness.

Manenti et al. (11) detailed the increasing cases of violence in health care institutions, which were also found from the narratives from Palestine. Cheung et al. (21) found that patients, their relatives, and colleagues were the foremost perpetrators of workplace violence. However, in this study, most of the violence came from the armed militia. The victims suffer irreversible physical and psychological harm. Thus, apart from amending policy so that there is zero tolerance for workplace violence in healthcare settings, hospitals located in war zones need to be properly guarded so that instances of violence are minimized (21).

Instances necessitating coordination of nurses and family were also found in the narratives from Palestine and Turkey. An example was the case whereby the mother needed to perform an oral aspiration on a child. These instances were associated with feelings of helplessness and the psychological tiredness of the families. Hamano et al. (22) noted that proper coordination of care between the nurse and family and among care providers leads to an improved quality of life of the patient, which can create positive feelings in the provider. Proper coordination of care is also vital for patients with multiple illnesses such as diabetes and cancer since it ensures that each provider performs their role, and in turn, no one experiences burnout (23,24). Thus, the coordination of care needs to be enhanced in various hospitals to create positive experiences for nurses and provide friendly hospital or family-centered care for bereaved patients.

Cases involving children were some of the most emotional experiences of nurses. Studies have suggested that considering the nurses’ conceptions of the child’s challenges is critical in fostering a positive relationship between the nurse and family, as it ultimately influences the treatment outcome (25). For children who are nearing the end of life, spiritual education is effective in easing their mental distress (26). Thus, nurses should be trained by chaplains, Imams, and other spiritual leaders on how to communicate spiritual meanings of illness and concepts of the afterlife to children so that they can be more relaxed in times of suffering, which may reduce nurses’ feelings of helplessness. Several studies have also detailed the importance of safeguarding of supervision of children. For example, Little et al. (27) found that safeguarding of supervision leads to more reflective practices for nurses, which then led to better practice. Thus, proper clinical supervision should be provided to ensure that not only the child’s needs are met, but also benefit the nurses through improved practice (27).

However, the study did not find significant differences between the nurses in Palestine and Turkey. The only slight difference was the high number of violence presented by Palestine participants. It was contrary to the expectation given the increased cases of violence in Palestine that have put stress on social amenities, led to population increase in some areas, and increased the number of casualties compared with Turkey, where the situation is relatively calm. Thus, the researcher suggests conducting a more detailed comparative study to establish the differences in nurses’ perspectives in the two countries.

Conclusion

Nurses are always in contact with the patients and are sometimes the determining factor between life and death. Their work environments are challenging, and sometimes, they encounter unforgettable events that leave permanent marks in their memories. These events create physical distress, which affects how nurses provide care to patients. Nurses also face other challenges, such as burnout and violence in the workplace. Sometimes, their colleagues or doctors fail to respect them or their insights, which may lead to the death of the patients. Thus, there is a need for better collaboration among healthcare professionals so that the views of each are integrated into the decision making. Moreover, there is a need for policy change to attract more nurses to the field, especially in the ICU, which will reduce stress and enhance the standard care provided to the patients at their final moments. Cases of violence are common, especially among Palestinian nurses. Therefore, hospitals in war-torn areas should be provided enough security to avoid any interruptions and ensure the safety of the health personnel. There is also a need to provide more education and opportunities for the nurses so that they can form positive attitudes toward care provision for patients at their end of life and in extraordinary events.

Ethics

Ethics Committee Approval: The study was approved by the Al-Quds University Ethics Committee (approval number: 30/01/2020, 100/REC/2020).

Informed Consent: Informed consent was obtained.

Peer-review: Externally peer reviewed.

Authorship Contributions

Surgical and Medical Practices: A.G.B., Ö.G.İ., Concept: A.G.B., C.K., T.O., Design: A.G.B., Ö.G.İ., C.K., T.O., Data Collection or Processing: A.G.B., Ö.G.İ., Analysis or Interpretation: A.G.B., C.K., T.O., Literature Search: A.G.B., Ö.G.İ., Writing: A.G.B., Ö.G.İ., C.K., T.O.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.