Introduction

Nurses have important roles and responsibilities during the COVID-19 pandemic and continue to be at the forefront of patient care and of interacting with patients infected with COVID-19 (Schroeder et al., 2020). Thus, nurses face a high risk of COVID-19 infection (Fernandez et al., 2020). One report identified that 38.6% (59,014) of the 152,888 healthcare workers infected with COVID-19 in 2020 worldwide were nurses (Bandyopadhyay et al., 2020). The consequence of a severe COVID-19 infection is death. According to the International Council of Nurses, in January 2021, the number of nurse deaths globally because of confirmed infection exceeded 2,710 cases (International Council of Nurses, 2021) and, in Indonesia, up to 339 nurses have already died because of COVID-19 (Databoks.katadata.co.id, 2021).

The death of a nurse is known to trigger a grieving process with a strong emotional response among their coworkers (Kostka et al., 2021). Mughal et al. (2022) explained that grieving is an outward expression of grief influenced by cultural and religious customs around death and the process of adapting to life after loss. Although grieving is a normal human response that should not be considered a psychiatric disorder, the World Health Organization's (2020) International Classification of Diseases, 11th Revision classifies the problem of grieving with long and persistent grief as a psychiatric problem that can increase the risk of various stress-related disorders, heart problems, addiction behaviors, immune system dysfunction, impaired quality of life, and suicidal ideation. COVID-19-related deaths represent a "perfect storm" triggering prolonged loss-related sadness. Nurses in the process of grieving have expressed increases in emotional, moral, and secondary traumatic stresses at work (Omran & Browning Callis, 2021). A concept analysis has defined the process of grieving in nurses as feelings aimed at the healthy resolution of loss and grief accepted through denial, anger, disorganization, reorganization, and depression (Brunelli, 2005).

For many nurses, coworkers are a "second family" with which they may share their important moments, solve problems, and celebrate successes (Laskowski-Jones, 2019). Studies show that coworkers can provide support to improve the quality of care, the handling of stressful situations in nursing, and job satisfaction (Khatatbeh et al., 2021). Yin and Zeng (2020) explained that coworkers helped satisfy the psychological need of nurses for interpersonal relationships during the pandemic.

Nurses grieving the loss of a coworker during the COVID-19 pandemic experience significantly increased psychological stress because of their concurrently high workload and grueling shift schedule burdens (M. M. Zhang et al., 2021). Increased psychological pressures accelerate burnout and turnover in nurses (Mirzaei et al., 2021) and exacerbate the already severe nursing shortage (Turale & Nantsupawat, 2021). Despite the many reports of nurses dying from COVID-19, few studies in the literature have addressed the impact of these deaths on nursing coworkers, resulting in a lack of information necessary to develop counseling and psychological support strategies for nurses who are continuing to handle the massive wave of COVID-19 cases.

Aim

This study was designed to elucidate the experiences of nurses in Indonesia facing the loss of a colleague who died during the COVID-19 pandemic.

Methods

Study Design

A phenomenological study design was used to explore the concept/phenomenon underlying the awareness of participants regarding the loss of a colleague during the COVID-19 pandemic. Phenomenological studies are conducted in realistic situations to minimize the limits to interpreting or understanding the phenomenon under study, allowing researchers to freely analyze the data obtained (Wojnar & Swanson, 2007).

Participants and Setting

The participants were 42 nurses spread across four provinces in Indonesia, including DKI Jakarta, Bali, East Java, and East Nusa Tenggara. The inclusion criteria included nurses who had lost a coworker in the same workspace, had known that coworker for more than 3 years, had worked in the COVID-19 isolation ward, were willing to share their experiences, and scored > 25 on the Inventory of Complicated Grief (ICG). An ICG score greater than 25 correlates with the presence of significant impairments in social, general, mental, and physical health functioning and loss-associated bodily pain (Prigerson et al., 1995). Individuals with multiple bereavement problems are generally the most informed individuals. Exclusion criteria included nurses who had communication problems during the interview, nurses who refused to be interviewed because of emotional instability, and nurses infected with COVID-19. A demographic datasheet was used to collect information on gender, marital status, years of service, religion, and culture.

In this study, 12 nurses were excluded from the interview process because of communication problems during the interview process, being infected with COVID-19, and not meeting the specified inclusion criteria. Data saturation was reached with the 23rd participant. The first eight participants were recruited using purposive sampling to increase maximum variation, with the remaining 34 participants recruited by snowball sampling. The recruitment process for participants was performed in each province via a national nurse organization network, and initial contacts were made with participants through care unit managers.

Data Collection

In this study, interviews were conducted via the online Zoom remote conferencing application using a semistructured approach between December 2020 and August 2021. Four of the researchers had received formal training in qualitative research. Two of the authors served as interviewers and explained to each participant the purpose of the study and relevant details such as the interview method used and the need for voice recordings. All of the collected information was kept confidential. Before the interview, the researcher conducted an ICG questionnaire with the participant to identify their level of sadness. Each interview lasted 90 minutes and was conducted in Indonesian. Each participant participated in the interview process twice to ensure the truthfulness of the information provided. The interview guide included questions addressing the following: (a) feelings and experiences after losing a coworker, (b) opinions regarding support needed, (c) coping strategies used to deal with the grieving process, and (d) future expectations. The researcher adjusted the phrasing and sequence of questions based on the circumstances in each interview session. The researcher made every effort to maximize dialogue and maintain an empathic understanding of the participants' symptoms and feelings. During the interview, observational notes on participants' affective responses (e.g., laughter, tears, sadness, impatience) and sensitive words were recorded to provide contextual information for subsequent analysis work. After being interviewed, all of the participants were provided psychological counseling by the third author (who is a certified professional counselor).

Data Analysis

Following Braun and Clarke (2006), thematic analysis was used to accurately capture the grieving experience of each participant. The analysis process begins with the researcher familiarizing themself with the data by listening to each interview tape before transcription. Four researchers heard the recorded content once after the interview session to understand the participants' statements. Next, two researchers copied and translated the interview data into English and then provided comments. Each data item useful in answering the research question was then coded.

Subsequently, coded data were analyzed, with different codes combined according to an ordinary meaning to form themes and subthemes. Two of the researchers reviewed the relationships between the data items and codes that informed each theme and subtheme to form a coherent, logical pattern and contributed to the overall narrative of the data. Two other researchers assessed how well the themes interpreted the data in terms of the research question. After the candidate themes were determined, the themes were named based on a detailed analysis of the thematic framework. Each theme provides a coherent and internally consistent data report that does not overlap with the other themes. The four authors established the themes reported in the final data analysis phase. The themes were connected logically and meaningfully to build a convincing data narrative.

Trustworthiness

Trustworthiness in this study was ensured following the steps of Denzin and Lincoln (2017), including credibility, transferability, dependability, and confirmability. Credibility was achieved by conducting two interviews with the participants to explore their experiences in detail and by engaging for extended periods with participants to ensure that participants fit with the purpose of this study and that the data obtained addressed the research objectives. Credibility was also achieved by allowing participants to share experiences without providing other opinions and by recording participant expressions in field notes to facilitate the data coding process. The improvement of data transferability was achieved by using sampling methods and qualitative research designs, using research problem background information from previously published research, clearly defining the demographic data characteristics of participants, and identifying 42 participants with sufficient conditions for qualitative research. Thus, dependability was achieved, a clear and targeted detailed research protocol was drafted, and the four researchers rechecked the accuracy of the data during the data analysis process. Confirmability was implemented by triangulating investigator data. This process included engaging several researchers in the interview process; keeping a diary related to research developments that determined the topics, methodologies, data analysis, results interpretation, and conclusions; and conducting regular research team meetings to discuss interpretations, codes, and themes. Furthermore, decision making at each research stage was documented for tracking and follow-up actions.

Ethical Considerations

Ethical approval was obtained from the Citra Bangsa University Committee, Kupang, Indonesia (reference number: LB 02.03/1/0049/2021). Permission from the hospital director was received before data collection. All of the prospective participants were given a research information sheet regarding the purpose of the study, the role of the researcher, data confidentiality protocols, the right to withdraw, and the length of the interview. Written consent was obtained from each participant before interviews were conducted. Permission was obtained directly from the nurses involved in the study.

Result

Thirty participants who had lost their coworkers volunteered to participate in this research interview. Data saturation was reached at the 23rd participant. The 23 participants consisted of 12 men and 11 women. Most were from Jakarta and East Java, with eight participants each. The average age of the participants was 37-41 years, 11 were married, ICG scores ranged between 25 and 36, most held a 3-year diploma as their highest level of education, and 11 of the participants were Muslim. The themes identified in this study, which describe the stages of dealing with grief because of the loss of a coworker, are shown in Table 1.

Table 1. Themes and Subthemes

Theme 1: Responses in the First Stage

Shocked to hear of colleague's death

Shock and rejection were common reactions of participants to hearing about the death of a coworker. Denial does not mean denying that a loss has occurred (although this may be the case) but rather involves denying the experience of all feelings. In addition, when nurses experienced the COVID-19-related loss of coworkers during the initial pandemic wave in March 2020 and May 2021, they were often unprepared because of the low level of awareness and psychological support received. They expressed regularly feeling nervous and confused, being sweaty, and experiencing an increased heart rate. Moreover, colleagues who died were immediately cared for by them.

When my companion died, I fainted, and my vision suddenly darkened. It went too fast, and I didn't expect it. (Nurse 23)

As he was dying during the chest compression process, it tugged at my heartstrings. I'm worried that the compression action I'm doing is too slow or I'm doing it wrong. When the rescue failed, my hands were still shaking. (Nurse 13)

Self-blame for failing to save a life

The participants "self-stigmatized," self-perceiving themselves as "losers," "unfaithful people," "unlucky," and "bitter" for failing to save the lives of their comrades.

The person closest to my life has left me; I don't want to live in the world. I was the one who failed to help him when he needed me. (Nurse 6)

I feel unlucky, and I'm not a good friend. I thought I did not have the face to meet my best friend after death. (Nurse 18)

Afraid to experience the same situation

The COVID-19-related death of coworkers made nurses feel anxious and afraid that they may also experience a similar fate. The expressions of fear conveyed by the nurses relate to a traditional Indonesian belief that people who have died will haunt those still living.

I am a single parent and have a small child at home who needs my attention; I am worried that if I get infected with COVID-19 and die like my colleague, there will be no one to take care of my child. (Nurse 2)

My colleague who died was my best friend since childhood. We were not married and lived together in a rented house when he died. I was afraid and had to flee to my brother's house, but he is still always present in my dreams to this day. (Nurse 14)

Theme 2: Responses in the Second Stage

Make efforts to avoid the same thing from happening again

The participants reported feeling sorry for the death of their coworker and making concerted efforts to prevent the same thing from happening to others. They focused on their work and treated every patient with COVID-19 with the utmost care. In addition, some of the participants repeatedly reminisced about the death of their colleague and their mistakes and worked to improve their efforts to prevent deaths from COVID-19.

The most important thing is to keep working and not make mistakes. We must have a clean conscience when dealing with COVID-19 patients, especially when dealing with death and comforting bereaved family members. We must do it wholeheartedly. If we have a clear conscience, our sorrow is reduced. (Nurse 1)

Every time I go home, I reflect on my day's work. For example, after some patients died from asphyxiation, I thought about whether there were errors in the treatment procedure. (Nurse 22)

Develop strategies to avoid thoughts of loss

One participant tried to suppress their emotions in the face of the death of a coworker and only vented negative feelings after the process was complete. The participants also revealed that turning to religious beliefs helped them rationalize the loss and life after death.

I did some sports, learned to dance, and cared for cats. I get flooded every day. Staying busy allows me to forget my dead co-workers. (Nurse 4)

If I feel broken, I pray to release it, and I believe good people will live in peace in heaven. (Nurse 17)

Expect to have a psychological support system

Nurses face great psychological stress when dealing with the death of coworkers and desperately need the understanding and support of those closest to them. After witnessing death, nurses feel physically and mentally exhausted and need emotional help.

Sometimes I tell my family about my best friend's death, and they say I'm pessimistic and I don't like hearing it. I want them to empathize with me. (Nurse 19)

Usually, I comfort patients and their families by being more open-minded and optimistic. However, when I am depressed, there is no one to comfort me. I am forced to let the feeling fade with time. (Nurse 13)

Theme 3: Responses in the Third Stage

Seek new reasons, goals, directions, and meanings in life

Resetting life goals refers to rearranging one's life based on the wishes of a deceased friend, the wishes of others, or personal expectations. In other words, the participants sought out new reasons, purposes, directions, and meanings in life. They also expressed that they valued their deceased colleagues as showing the way to a new life path through continued bonding with material means and spiritual connections.

I thought about what my best friend said when he was alive about continuing my education. Now I am preparing for it (continuing education). (Nurse 11)

We once intended to do charity in an orphanage. Now, I do charity. This is also a way to fulfill my best friend's wish. (Nurse 4)

Improve the physical and social health of individuals

Improving health refers to the maintenance and improvement of physical and social health. The participants sought to improve physical fitness or reduce illness, especially to avoid problems with their coworkers.

I bought some traditional medicine to drink to boost my immunity (Nurse 8)

I have hypertension. I have a blood pressure meter. I take my blood pressure every day (Nurse 16)

Discussion

The participants displayed eight subthemes in three stages to deal with the death of a coworker during the COVID-19 pandemic. The emotional expressions in the first stage included (a) being shocked to hear of colleague's death, (b) blaming oneself for failing to save a life, and (c) being afraid to experience the same situation. The actions in the second stage included (a) making efforts to avoid the same thing from happening again, (b) developing strategies to avoid thoughts of loss, and (c) expecting to have a psychological support system. The changes in the third stage included (a) seeking new reasons, goals, directions, and meanings in life and (b) improving the physical and social health of individuals.

The participants showed strong emotional expressions after the death of their coworkers. Studies show that death is a universal human experience and a very dynamic and painful event. When a loved one dies, one is left to grieve for the loss (Morrissey & Higgins, 2021). The various emotional responses related to death found in this study, including nervousness and confusion, shock and denial, deep sadness, self-blame, anxiety, and fear, are in line with a previous study on nurse responses to patient deaths by Khalaf et al. (2018), who found nurse reactions to loss to include sadness, crying, angry, shock, denial, and feelings of guilt.

Although nurses are expected to offer information, guidance, and emotional support to patients and their families before and after death, losing a loved one has a profound effect on their own emotional status that is difficult to control (Makwana, 2019). Nurses experience the loss of life and witness the pain and suffering of the dying and the sorrow for the bereaved. For nurses, especially in environments such as emergency departments and intensive care units where the focus is on preserving life, death can represent failure and thus be a source of stress (Jackson et al., 2020).

Deaths among nurses naturally heighten feelings of tragic loss for those left behind. Of all human experiences, death is the most painful and far-reaching emotional adaptation challenge for families. Failure to manage feelings of grieving can result in an increase in complicated grief, also known as persistent complex bereavement disorder. This is a phenomenon characterized by long-term and severe painful emotions that cause an individual to face difficulties in recovering from their loss and continuing everyday life as normal (Duffy & Wild, 2017).

When experiencing emotional stress, nurses try to pursue coping strategies such as working hard and conscientiously, venting their emotions, reflecting and improving the quality of work, accepting the loss, and implementing self-control. Coping developed by nurses may be seen as an effort to reduce the adverse effects of emotional problems. However, unhelpful coping strategies can exacerbate emotional distress (Smith & Ehlers, 2023). Thus, nurses must learn to accept their loss and implement self-control. Schnell and Krampe (2020) found that self-control can suppress one's emotions.

Nurses express a diversity of emotions in response to loss-related sadness that allow them to focus on improving the quality of work and working more carefully. The findings in this study align with M. Zhang et al. (2021), who examined nurses' coping strategies during the home isolation period for COVID-19 pandemic in China. All of the interviewees in that study stated that negative emotions could be effectively eliminated by shifting attention toward interests. They preferred to focus on their work and chose to do leisure activities.

Nurses must adopt effective coping strategies that reflect the conditions experienced when dealing with emotional stress. Because no coping strategy is definitively good or bad, coping will be effective only when it suits the individual character. Appropriate coping strategies can reduce or buffer the harmful effects of emotional problems (Liang et al., 2020).

The course of the coping process necessarily reflects the personal resource and social support situation of each individual (Babicka-Wirkus et al., 2021). In this study, the participants required adequate psychological support from their families and organizations to improve their ability to cope with the death of a coworker. The absence of support can increase perceived stress. Previous studies have shown that support from families, organizations, and supervisors received by nurses can effectively reduce their perceived stress (Y. Zhang et al., 2020).

Organizations must provide training to increase knowledge of relevant coping strategies among nurses, especially those who have experienced the loss of a coworker during the pandemic. Studies have shown that nurses with a better understanding of coping strategies are better able to control their emotional stress (Wazqar et al., 2017). Effective coping strategies and support provided to nurses can encourage nurses to extricate themselves from their problems and start a new way of life.

Another theme revealed in this study is that the loss of a coworker led participants to rethink and change their own course in life. The participants in this study chose to honor their deceased colleagues, reset their life goals, and enhance their own health. In this phase, nurses enter a period of acceptance and understand that life can and will go on (Oates & Maani-Fogelman, 2021). In this stage, life habits may be rearranged. While listening to their own needs and developing forward, nurses have not forgotten their departed comrade, as the bereavement phase can persist for multiple years (Mughal et al., 2022). Previous studies have shown that the process of adjusting to the loss of a loved one often involves conducting activities such as celebrating birthdays, praying, and trying to live a healthier life (Entilli et al., 2021).

Limitations

This qualitative research has limitations that must be acknowledged. First, this study focused on a small sample of nurses. To generalize the findings and help improve the grief problems experienced by nurses in general, future studies should use qualitative and quantitative methods on much larger and more-representative samples. In addition, interviews should be conducted face-to-face for optimal communication of meanings. Finally, some of the findings of the participants may have been influenced by the Indonesian cultural context. Thus, further studies should be conducted in other country and social settings to examine similarities and differences.

Conclusions

The experience of nurses facing the death of a coworker in this study included several stages of responses. First-stage responses included (a) shocked to hear of colleague's death, (b) self-blame for failing to save a life, and (c) afraid to experience the same situation; second-stage responses included (a) make efforts to avoid the same thing from happening again, (b) develop strategies to avoid thoughts of loss, and (c) expect to have a psychological support system; and third-stage responses included (a) seek new reasons, goals, directions, and meanings in life and (b) improve the physical and social health of individuals. The insights gained from this study may be used to inform clinical practice and provide evidence for establishing effective approaches to providing psychological support to nurses experiencing coworker loss, especially those in the first-stage response period.

Implications for Practice

Grief is the most common symptom experienced by nurses who have lost a coworker during the COVID-19 pandemic. However, little research and attention have been paid to this sad and devastating situation in clinical practice. The findings from this study have important implications for healthcare providers wanting to develop targeted interventions to assist nurses to deal with coworker loss. The various coping strategies described by participants in this study provide sufficient detail for healthcare providers to deal with grieving nurses more comprehensively. The findings of this study suggest that healthcare providers should adopt plans that are in harmony with the beliefs and needs of their nurses and that these plans are particularly important now, as the threat of the COVID-19 pandemic and COVID-19-related nurse deaths has not disappeared. Although some of the strategies used by the participants were specific to the situation of nurses, most were applicable beyond the narrow scope of nursing. Therefore, these strategies may be considered and adopted by healthcare providers to improve the quality of services provided to nurses and, ultimately, to support the ability of nurses to provide quality care to patients.

Acknowledgments

The authors thank the participants for sharing their experiences and hospital staff for their assistance with recruitment.

Author Contributions

Study conception and design: All authors

Data collection: PKST, HMAD

Data analysis and interpretation: All authors

Drafting of the article: PKST, YMKL

Critical revision of the article: HMAD, MYB, PKST

References