Undergraduate Nursing Students Knowledge Regarding Grief Counseling at the tertiary institution in Namibia

Introduction

Grief counseling is a procedure intended to help the client grieve in a healthy manner, to understand and cope with the emotions they experience, and ultimately to find a way to move on and this can be accomplished through existential therapy, individual therapy, group therapy, and/or family therapy [1]. Grief counselors might focus on issues such as individuals who lost a co-worker, children coming to terms with the loss of a parent, a friend or a pet, patients in hospice care, women or couples who are dealing with a miscarriage and people who have gone through traumatic events [2].

It is very common for people to avoid talking about their sadness, but they may not realize the effects of grief and how it may affect a person to move forward [3]. Talking to a trained professional that understands grief loss and bereavement helps one put their situation into perspective while learning how to cope with emotional hurting [3]. In addition, it helps them develop new skills and learn more about themselves and about life. It can help them grow stronger even as they face a devastating loss, grief counseling can help anyone who is going through a major loss, but for some it’s crucial to get help. If one’s pain is overwhelmingly intense, lasts for over a year, or is affecting the way they function in their daily lives, grief counseling is one of the best ways to deal with the loss and find your way forward [3]. When the grieving process is interrupted or incomplete it could cause complicated grief with the name persistent complex bereavement disorder (PCBD) [4].

Nursing students are required to do their practical at health care institutions and they are constantly exposed to grief counseling. When a patient is approaching death, relatives need to make a transition from focusing on recovery for their loved one to preparing for their avoidable death [5]. Nurses’ roles are to help the family, loved ones to engage in the grief process, and may assist them in attempting to reconstruct their lives after a loss [6]. Nurses play an important role in supporting families at the time of their loss by considering their unique spiritual, ethnic and cultural background [6]. When providing these massive important responsibilities, student nurses must be effectively prepared and organized to offer sensitive quality care to the bereaved families or those affected. There is a need for sufficient clinical experience in this area in order to improve the knowledge of the student nurses to reduce their concerns about giving comfort to the bereaved.

According to Mokgele, death is one of life’s new certainties and a universal experience for all individuals [7]. When a death occurs, there is usually an impact on the family and friends of the deceased, the magnitude of which often depends on whether death was expected or unexpected. Loved ones are left behind to go through the grieving process [7]. In Australia it has been estimated that between 10% and 20% of bereaved people experience complicated grief. Rates are higher amongst those bereaved by disaster, violent death or parent who lose a child [8].

A South African study by Thurman, regarding the effects of bereavement support group on female adolescents stated that early bereavement is common in South Africa, where almost a fifth of children have lost a parent and many more have experienced a death of another family member or a friend. Despite the serious potential consequences of bereavement in childhood, including the risk for depression, maladaptive grief and other emotional and behavioral problems, few evidence- based bereavement support services are available to children in South Africa [8].

The study conducted in Namibia by Taukeni, regarding orphaned learners’experience with regard to bereavement support, mentioned that many researchers and practitioners found that bereavement support is beneficial, useful and meaningful within the school setting. Bereavement support in a school setting can potentially assist the bereaved children and their family in strengthening their resources for dealing with the death [9]. However, little is known about the knowledge of undergraduate student nurses regarding grief counselling, hence this study.

The Aim of The Study

The aim of the study was to determine the knowledge regarding grief counseling amongst the four-year nursing students at the tertiary institution in Namibia.

Objectives of the Study

The research objectives of the study were to:

• Assess the knowledge of the fourth year nursing students regarding grief counseling at the tertiary institution in Namibia.

• Describe the knowledge of the fourth year nursing students regarding grief counseling at the tertiary institution in Namibia.

Materials and Methods

Research Design

A quantitative, cross sectional, descriptive study research approach was employed to assess the knowledge of the undergraduate degree- nursing students on grief counseling at the tertiary institution. This approach was found appropriate since the researchers wanted to quantify the problem by a way of generating numerical data or data that can be transformed into useable statistics.

Population, Sample and Setting

The target population of this study was 105 undergraduate nursing students (4th year degree nursing students) based at the tertiary institution and it is where the study was conducted. The researcher used a simple random sampling method, which indicated that every participant has an equal chance of participating in the research. The sample size (n) was determined using the “Yamane formula” namely according to Brink et al., [10]. The sample size for this study was 83.

Research Instrument

The researchers developed multiple- choice questionnaires to obtain data via online from the undergraduate degree nursing students based on the objectives of the study. Online questionnaires were easy to complete, especially the time of COVID-19, since it reduces handling of "lots of forms/documentation", hence link was provided to each participant. The researcher typed the questionnaire in English which is the medium of communication in the University. The questionnaires consisted of four sections A, B, C and D with closed ended questions where students choose from given alternatives. The Likert agreement was used to measure the knowledge regarding grief counseling with a variety of states ranging from strongly agree to strongly disagree.

Instrument validity was ensured in a way that the questionnaires were pretested in order to eliminate misleading questions and rule out aspects and factors that may have interfered with the understanding of the student. Validity was also ensured by the fact that the study participants were only chosen from the tertiary institution and it will not be generalized to any other institution as mentioned in the samples and sampling methods. The questionnaire consisted of questions that covered the whole content of the study. Reliability was ensured by testing the tool through a pilot study and using the tool that has already been tested for reliability.

Data Collection

The researcher distributed the questionnaires to the undergraduate degree nursing students online so they may complete it at their own convenient time and gathered the data. The questionnaire was handed over to the students online and after completion Google form recorded the results. The researcher obtained primary data directly from the 4th year nursing students. Prior to the full scale study, the researcher carries out a pilot study with third year students to identify any problems with the questionnaire and determine whether the questions were clear and understandable to the participants and to make necessary adjustments to the instrument based on the outcomes. Due to the positive feedback from the participants, the researcher was able to get a go ahead with the main study. The data of the pilot study did not form part of the final study.

Data Analysis

Data analysis is the methods and processes for analyzing data, it entails categorizing, ordering, manipulating and summarizing the data [11]. The data collected using Google form and the data were analyzed using Google spreadsheet. The researcher made use of descriptive statistics like measures to condense the data. Descriptive statistics were used to describe basic features of data in a study and include frequent distribution, central tendency of the main variables such as knowledge. These statistics convert and condense a collection of data into an organized visual representation in a variety of ways, so that data has some meaning. The data of this study were analyzed using descriptive statistical analysis and the results were presented accordingly in line with the objectives of the study. The sample size of this study was 83 participants but under unpredicted circumstances, only 78 questionnaires were answered. Google form recorded the results. The researcher first presented the demographic data of the participants and secondly the results regarding the assessment of the knowledge of the undergraduate degree nursing students on grief counseling.

Ethical Considerations

The Ethical committee members at the tertiary institution in Namibia permitted this research. Regarding the principle of respect, the participants were asked to participate willingly in the research without feeling pressured as they had the right to withdraw from participating in the study at any given time with no expected explanation. Privacy, confidentiality and anonymity were considered in this study, no name was requested, and all information was treated confidentially and privately. Participants were given an informed consent form, which they have to sign individually so they can decide as to whether or not to participate in the study without the risk of penalty or discrimination. Regarding the principle of beneficence and non- maleficence, the researcher did not ask uncomfortable questions to participants or forcing the participants to discuss personal and sensitive matters. For justice, the researcher treated the participants fairly by means of fair selection in terms of recruiting study participants.

Results

Section A: Demographic Data

A total of n= 78 participated in this study and a response rate of 100% was achieved. Gender: majority of the participants that took part in this study were females with the frequency of 92.3% and minority were male with the frequency of 7.7%.The participants were of different ages, 1.3% was at the age of 20, 24.4% were at the age of 21, 21.8% were at the age of 22, 24.4% were at the age of 23, 12.8% were at the age of 24, 1.3% was at the age of 25, 2.6% were at the age of 26, 1.3% were at the age of 27, 1.3% were at the age of 29, 1.3% were at the age of 30, 1.3% were at the age of 31, 1.3% were at the age of 32, 1.3% were at the age of 34, 1.3% were at the age of 35, and 2.6% were at the age of 36. The majority of the participants, 88.3%, obtained grade 10 and grade 12 certificates, 10.4% participants obtained certificates in nursing and 1.3% participants obtained a diploma in nursing. Only 9% of the participants were previously enrolled as nurses while 91% of participants were not. The majority of the participants 96.2% were Namibian while 3.8% were other nationalities.

Section B And C: Assessing the Knowledge on Grief Counsel- ling

The participants were asked to Agree or Disagree to the statements provided in the questionnaires (Table 1) under Section B

To the question, whether the grief counseling is only for those who lost a loved one. The majority 47.4 % of the participants agree that grief counseling is only for people who have lost a loved one and 52.6% disagree. Whether the Grief counseling is a form of therapy. The majority, 98.7% of the participants, agree that grief counseling is a form of therapy and 1.3% disagree. Whether it is not mandatory for the nurses to give proper and effective grief counseling. Only 21.8% agree that it’s mandatory for nurses to know how to give proper and effective grief counseling while majority 78.2% disagree. If all people can benefit from grief counseling: 97.4% of participants agree that all people can benefit from grief counseling and 2.6% disagree. To the question whether adults do not grief, therefore they do not need grief counseling: Only 2.6% of participants agree with the statement and 97.4% disagree. If grief has stages, shock, and denial is one of them: The majority 94.9% of the participants agree that grief has stages and shock and denial is one of them while 5.1% disagree with the statement. There are no educational requirements to become a grief counselor: Only 28.2% of participants agree that there are no educational requirements to become a grief counselor while 71.8% disagree. Whether Humor can help the bereaved adults in their grieving process: 93.6% participants agree that humor can help the bereaved adults in their grieving process while 6.4% disagree. Consent is needed to offer grief counseling: 46.2% of participants agree that consent is needed to offer grief counseling and 53.8% disagree.

Table 1: Knowledge about Grief Counselling

The participants were furthermore asked to Strongly agree, Agree, I do not know, Disagree, Strongly disagreed to the statements provided in questionnaires (Table 2) under Section C

A total number of 2.6% participants strongly agreed, 3.8% agree, 12.8% do not know while 51.3% disagreed and 29.5% strongly disagreed that grief counseling is only given at the hospital. 51.3% of the participants strongly agree that asking sensitive questions may trigger the grieving process, 37.2% agreed, 5.1% do not know, 3.8% disagreed and 2.6% strongly disagreed. 34.6% of participants agreed that there are many interventions that can be used to support the bereaved after their loss, 56.4% agreed, 9% do not know. The majority of participants agreed 48.7% that cultural background plays a role in grief counseling, the minority have disagreed 3.8% with the statement. Some variables are clearly presented in table 2.

Table 2: Knowledge about Grief Counselling

Section D: Assessing the Specific Knowledge on Grief Counselling Process (Table 3)

The participants were asked to Agree, I don’t know or Disagree to the statements provided in the questionnaires (Table 3) under Section D

Create a helping environment by finding a quiet, private place to talk, projecting warmth, interest and respect; all the participants 100% agreed. Begin the first encounter by asking the bereaved to tell you about the death: 52.6% agreed, 24.4% indicated that they don’t know and 23.1 % disagreed. Ask about other difficult times in his/ her life: The majority 66.7% agreed, while 14.1% indicated that they don’t know, only 19.2% disagreed. Ask what coping skills he/she utilized in past crises and encourage them to utilize those same resources in the current crises. The majority 85.9%, 10.3% indicated that they don’t know, only 3.8 % disagreed. Ask about their relationship with the deceased: 92.3% agreed, 5.1% indicated that they don’t know, and 2.6% disagreed. Remind the survivor that it is normal to feel overwhelmed by the intensity of his/her feelings: 93.6% agreed, 3.8% don’t know, only 2.6% disagreed. Allow the bereaved to mourn and express themselves: 97.4% agreed, 1.3% indicated that they don’t know while another 1.3% disagreed. Actively listen to the grieving person without interruption: The majority 98.7% agreed, 1.3% indicated they don’t know and no one disagreed. Recognize that pain and denial is the biggest part of the grieving process after the loss of a loved one: The majority 96.2% agreed, only 2.6% indicated that they don’t know, while 1.3% disagreed.

                                                                 Table 3: Knowledge on grief Counselling Processa

Discussion

Section A: Demographic data A

total of 78 undergraduate degree nursing students at the tertiary institution participated in the study, out of the 78 participants, 92.3% of the participants were female, while 7.7 were male. Nursing was perceived to be a female profession in the past, and it still results in fewer males to pursue it as a career. This result is similar to the study that was conducted by Newsom, in the Netherlands on the effectiveness on bereavement counseling were the majority of the participants were female [12]. In this study most of the participants, 83.4%, were from the age range of 21- 24 years. These results are in contrast with a study conducted by Horn, in South Africa on evaluating a grief program where the majority of participants were between ages 7-17 [13]. Most of the participants 88.3% had grade 10 and grade 12 certificates, 10.4% had obtained a certificate in nursing while 1.3% had a diploma in nursing. As the majority were of the ages ranging between 21-24, which correspond with their highest level of qualification. Few,9% of participants admitted that they were previously enrolled as nurses while many, 91%, were not. From the 78 participants it was also found that exactly 96.2% were Namibians while 3.8 fell in the category of others.

Section B, C, and D

47.4% of the participants agreed that grief counseling is only for people who have lost a loved one and the majority 52.6% disagreed. According to Gupta, grief counseling also known as bereavement therapy, is a form of therapy that has intended to help a person to cope with loss, like the death of a partner, family member, friend or pet [14]. It is revealed that the majority of participants are knowledgeable that grief counseling is a form of therapy. Furthermore, the minority participants 21.8% agree that it’s not mandatory for nurses to know how to give proper and effective grief counseling while majority 78.2% disagree. This is a crucial fact and it is compulsory that all nurses should provide grief counselling to prevent complication of grief and can be the reasons why students are ignoring grief counselling. In contrast, a study by Mousavi, Pottal and Podder assesses the knowledge and attitude of staff nurses regarding perinatal bereavement care and correlative knowledge of staff nurses regarding perinatal care have found that, the majority of staff nurses have average and little knowledge and positive attitudes towards perinatal bereavement care [15].

It is also revealed in this study that 97.4% have agreed that all people can benefit from grief counseling while a minority of 2.6% disagree. Similarly, a study conducted by Rugonye and Bukaliya, on the effectiveness of African bereavement counseling techniques in Zimbabwe were 60% of his participants agreed African counseling is very powerful in assisting all those bereaved. Oates and Maani further stated that grief and loss are something that all people will experience in a lifetime. Grief counseling facilitates the healing process of grief [16]. It is also revealed that the minority participants, 2.6%, agreed that adults do not grief, therefore they don’t need grief counseling and 97.4% disagreed. Participants portrayed that they some knowledge that there is no exclusive age for grief.

Many participants, 94.9%, agree that grief has stages and shock and denial is one of them while 5.1% disagree with the statement. Most of the participants are knowledgeable about the stages of grief which are initially 5 including shock and denial. 28.2% of participants agree that there are no educational requirements to become a grief counselor while 71.8% disagree. In comparison to a study by Van Mol, Wagener and Latour, about developing and testing a nurse- led intervention to support bereavement in relatives found that majority of his respondents do not require bereavement support from a specialist (such as a psychiatrist or a psychologist). According to Pastoral Counseling.org becoming a grief counselor takes years of education, practical experience and licensing. Furthermore, 93.6% of participants agree that humor can help the bereaved adults in their grieving process while 6.4% (n= 5) disagree. Study by Bennet, proved that despite the popular notion that humor is inappropriate during difficult times, humor and laughter can actually help us cope with tough losses [17]. Similarly, in a study conducted by Horn and Govender, all participants stated that they were mostly impressed about the facilitator’s sense of humor and empathic qualities the most impressive [13].

The majority of the participants, 53.8%, disagreed with this question. In contrast, Shah and Thornton, argued that informed consent is mandatory for all clinical trials involving human beings [18]. The consent process must respect the patient’s ability to make decisions. All the participants 100% agree with this statement, this indicates that they have sound knowledge on the aims of grief counseling. Similarly, Adikwu adds that grief counseling also treats your trauma, builds a strong support system to help you carry on. The majority of the participants disagreed that grief counseling is only offered in the hospital. Many others strongly disagreed while only a few participants strongly agreed and agreed that grief is only offered in the hospital. These results are similar to a study by Varga, et al., conducted on the holistic grief effects, mental health and counseling support in bereaved college students whereby students are provided with grief support on campus and also many students have shown utilizing social media as grief support in various ways and report that support as helpful [19].

The majority of the participants, 69.2% strongly disagreed that nurses should not give grief counseling, 28.2% disagreed, only 1.3% didn’t know and 1.3% strongly agreed. As a nurse, one has the honor to take care of the most vulnerable populations, it is the role of the nurse to provide compassionate care to the patient and their loved one [16]. Most of the participants, 79.6%, strongly agreed that feeling sad after the loss of a loved one is normal with the question, more have agreed and only 1.3% disagreed. The result also proves that participants know some symptoms of grief that include sadness. Grief may affect individuals differently but can be exhibited through signs and symptoms such as altered immune response, anger, sleep disturbances [16].

Most of the participants are aware that asking sensitive questions may trigger the grieving process. 66.7% of participants strongly disagreed that only children should be offered grief counseling after the loss of a loved one 32.1% disagreed with the question and only 1.3% strongly agreed. It proves that the participants have knowledge that anyone can get grief counseling at any given age because grief affects everyone. Only 9% participants strongly agreed that grief can cause inflammation that can kill, 9% agreed and majority of 41% of participants did not know whether grief can cause inflammation that can kill. According to new research from Rice University grief can cause inflammation that can kill. Only 34.6% of participants strongly agreed that there are many interventions that can be used to support the bereaved after their loss and the majority of 56.4% agreed that there are many interventions that can be used to support the bereaved after their loss, 9% did not know [20]. These results are similar to a study conducted by Horn and Govender, about evaluating a school program were most of the respondents agreed that variety of creative techniques help learners to process grief in a developmentally appropriate manner [13].

The majority of the participants 55.1% strongly agreed that grief has 5 stages which include anger, denial, bargaining, depression and acceptance, more of the participants agreed 34.6% a few did not know 7.7% and only 2.6% strongly disagreed. The participants have a familiarity with the stages of grief as proven by the results. The majority of participants 38.5% strongly agreed that Cultural background plays a role in grief counseling 48.7% agreed 9% did not know, and only 3.8% strongly disagreed. Similarly, a study conducted by Rugonye and Bukaliya, on the effectiveness of African bereavement counseling techniques in Zimbabwe were majority of the respondents agreed that they are assisted by cultural techniques to change their behavior [21]. However, 40% were in total disagreement. Cancer Net, argued that in each culture, death is associated with rituals and customs to help people with the grieving process [22].

Regarding knowledge on grief counselling process, all the participants 100% in this study have agreed that you need to create a helpful environment by finding a quiet, private place to talk which projects warmth, interest and respect. The results prove that participants have knowledge of the criteria of the environment when giving grief counseling. Most of the participants 52.6% agreed that begin the first encounter by asking the bereaved to tell you about the death fewer 24.4% did not know and 23.1% disagreed. The results show the knowledge gap regarding the process of the first encounter with a bereaved person. Courtney and Ackerman stated that you can begin your first encounter by asking the bereaved to tell you about the death [23]. Many 66.7% participants agreed that they ask about other difficult times in his / her life, 14.1% did not know and 19.1% disagreed. In this study participants have knowledge that how someone responded to past losses can tell a great deal about how they are likely to adjust to the current loss.

The majority of the participants, 85.9% agreed that it will be good to ask what coping skills he/she utilized in past crises and encourage them to utilize those same resources in the current crises, 10.3% did not know while only 3.8% disagreed. Participants have knowledge of the individual steps in giving grief counseling. The majority of the participants, 92.3%, agreed that it is good to ask about their relationship with the deceased. It is a way to provide support and encouragement. The majority of the participants, 93.6%, agreed that it is good to remind the survivor that it is normal to feel overwhelmed by the intensity of his/her feelings 3.8% did not know and 2.6% disagreed. In this study, participants have knowledge on the criteria of emotions that are encountered during grief counseling. Majority participants, 97.4% agreed that it is good to allow the bereaved to mourn and express themselves 1.3%, did not know and 2.6% disagree. Grieving is important because it allows us space to free up energy that is bound to the lost person so that we may reinvest that energy elsewhere [24].

The majority of participants, 98.7%, agreed that it is good to actively listen to the grieving person without interruption only 1.3% did not know and none disagreed. These results indicate that participants are knowledgeable about the importance of actively listening to the grieving person without interruption. These results are similar to the study conducted by Coleman and McLaughlin, on using role play to help student nurses with bereavement conversations where most (80%) of the student nurses admitted that the experience has increased their awareness on the importance of providing bereavement care and of supporting someone by listening to them and giving them time. Furthermore, the majority, 96.2%, indicated that it recognizes that pain and denial is the biggest part of the grieving process after the loss of a loved one, while 6% did not know and only 1.3% disagreed.

Conclusions

This study concluded that the knowledge of some undergraduate student nurses regarding grief counselling is limited [25-34].

Recommendations

The following recommendations were inferred from the study:

1) Grief counseling procedures to be inserted in the practical register and students should be constantly taught when they are on their clinical allocations and be supervised and guided to improve their practices and competency on rendering proper grief counseling when necessary.

2) Designating and distributing a booklet to all nurses who work in the wards to standardize nurse’s performance for grief counseling for them to teach students during their clinical practice.

4) There is no research that was done to determine the knowledge regarding grief counseling amongst the 4th year at the tertiary institution nursing students at any other tertiary institution in a Namibian context, thus more research from other tertiary institution campuses should be done on this topic in the future.

Limitations

This study suffered the following limitations: due to COVID-19 outbreak that interfered with the normal university work, participants were difficult to get, this limited the time for the data collection, and the study only focused on fourth year degree nursing students other than students from other nursing training institutions, this limits the generalization of the results to other students and other campuses. The required sample size was not obtained because some students were not willing to partake in the study. This study was descriptive in nature, therefore analyzing data was limited to descriptive only.

Acknowledgement

We thank all the authorities that granted us permission to conduct this study as well as the undergraduate degree nursing students who gave up their time to be involved in this study. Thank you.

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