Research Article, J Nurs Patient Care Vol: 2 Issue: 2

Exploring the Spiritual Growth Experiences of Nurses Caring for Terminally Ill Patients

Yung-Hua Liu, Wan-Ping Yang and Ya-Lie Ku^*

Department of Nursing, Fooyin University, Taiwan

*Corresponding Author : Ya-Lie Ku
Associate Professor, Department of Nursing, Fooyin University, No.151, Chin-Hsueh Rd, Ta-Liao District, Kaohsiung City 83102, Taiwan
Tel: 886-7-7811151-5612
E-mail: ns126@fy.edu.tw

Received: April 04, 2017 Accepted: May 12, 2017 Published: May 19, 2017

Citation: Liu Y, Yang W, Ku Y (2017) Exploring the Spiritual Growth Experiences of Nurses Caring for Terminally Ill Patients. J Nurs Patient Care 2:2. doi: 10.4172/2573-4571.1000115

Abstract

Keywords: Spirituality; Nurses; Experiences; Terminal patients; Narrative studies

Background

Holistic nursing is the core of nursing and it enables people to achieve a high, stable and harmonious status of physical, mental, social and spiritual level and find the significance and meaning of life. Holistic nursing is mostly required by terminal patients in particular [1-4]. Researchers pointed out that, when nursing personnel are facing parting and losing, their spirits are also impacted. As the events conduct frustrating, self-accusation, powerlessness and other feelings, it may bring impacts on holistic nursing and the attitude and response on death [5,6].

Wu et al. found that among 293 nurses in a regional hospital of north Taiwan, when their spiritual scores are higher, their spiritual nursing scores in self- assessment are better. However, 80% of them believe that own spiritual health is being ignored; comparing the spiritual demands from patients, few people care about the spiritual demands from nurses [7]. This is why the spiritual self-development of nursing personnel in clinics has significant implications. To assist nursing personnel to learn about spiritual self-development, Riessman et al. proposed a method that, through narrative research, guiding research subjects to tell their life stories and spiritual experience of nursing terminal patients; researchers then make up and create metastories while reflecting themselves and expecting positive thinking and attitudes, which can make enhancing of spirits [8].

Purpose of the Study

The purpose of this study was to explore the spiritual growth experiences of nurses caring for terminally ill patients.

Literature Review

Following literature review from 2002 to 2015 were related to nurses who have cared the terminal children and adult patients and their spiritual interpretations. For terminal children patients, Chen et al. explored the experiences of caring terminal child patients by 16 purposive sampling nurses in pediatric wards and pediatric intensive care of Taiwan by using qualitative research with depth interview [9]. Themes included evading death, medical dissension, guilt to parents, unforgettable about the child pain, nonconformance to standard in terminal nursing, relieving pressure and releasing after death. Lately, Huang et al. explored the predicament of caring terminal child patients by 15 purposive sampling nurses in pediatric wards and pediatric intensive care of Taiwan by using qualitative research and depth interview [10]. Themes included ignoring patient demands and decisions, lacking of support skills, medical dissension, palliative powerless, care time compression and no sorrow calming after patient’s death.

For terminal adult patients in foreign countries, Belcher et al. investigated the spiritual values of 204 hospice nurses applying for jobs of hospice in New England and America that identified integrate differences in faith and cultures, satisfying the spiritual demands from patients with arts, praying and other methods [11]. Noble et al. explored spiritual opinions of caring terminal patients by 7 purposive sampling nurses in oncology department of UK by using qualitative research and depth interview [12]. Themes of obstructing spiritual caring included the different definition of spirit, spiritual strategy, lacking spiritual care and communication training, and deficiency of time. Ekedahl et al. explored the faith sources for responding the terminal patients of 15 snowball sampling nurses in oncology department of Sweden by using qualitative research and depth interview [13]. Results identified 4 dimensions as dynamic life, faith protection function, praying response, and development of response resources. Khorami Markani et al. explored spiritual experiences from 20 muslin nursing terminal patients by purposive sampling nurses in oncology department of Iran by using qualitative research and depth interview [14]. Themes included finding the true God, life mission and goals, believing in rebirth, improving communication of spiritual cares, going beyond life. Browall et al. discussed experiences of the existing situations nursing terminal cancer patients by 83 randomized controlled trial nurses in oncology, hospice and surgery department from Sweden by qualitative research on the key techniques and record important events [15]. Themes included suffering misery experiences and meeting hope experience. Decker et al. discussed hospice experiences of nursing terminal cancer patients by theoretical sampling 25 nurses in Australia ER using qualitative grounded theory with depth interview [16]. Categories included non-hospice place, hospice strategy, ending of emergency treatment, lacking hospice nursing and being reluctant to let go.

For terminal adult patients in Taiwan and China, Tsai et al. investigated the situation of pressure, response and spiritual opinions of the newly appointed 19 random nurses in oncology department of Taiwan and explored their terminal caring experiences by using triangulation research with a scale of pressure, response and spiritual opinions and depth interview [17]. Themes identified as the physical and psychological changes, life touch, retaining links, professional behavior, response strategies, and spiritual value as love and kind faith. Chang et al. explored spiritual nursing cognition on terminal patients of 16 purposive sampling hospice nurses in Taiwan by using interpreting methods with depth interview [18]. Themes identified as spiritual content including physiological satisfaction, easing on mind, faith comfort, value pursuit in life, and relationships with peers. Lee, et al. explored spiritual meaning from 11 purposive sampling nurses in intensive care unit of Taiwan by using phenomenology design with depth interview [19]. Themes included spiritual meaning, personal spiritual essence, interpersonal interaction, ultimate belief for comfort. Liu et al. explored experiences of nursing terminal patients by 7 purposive sampling hospice nurses in oncology department of Taiwan by using hermeneutic phenomenology and depth interview [20]. Themes included nursing dilemma, self-weakness, and beingwith -others. Zheng et al. discussed experience of nursing terminal patients by 28 purposive sampling nurses in oncology department from China by using qualitative and descriptive research and depth interview [21]. Themes included physical and metal nursing in terminal period, caring to bereaved, the coordination of different customs, sorrow and weakness, self-examination of life and death, and trained advantages.

Overall, nursing personnel caring terminal patients are most from intensive, hospice and cancer units. The internal restricting of nursing personnel perform spiritual caring, include that spiritual content and explanation, experiencing and observing degrees of spiritual comfort, establishing values and goals of life and spiritual response strategy; while external restrictions include medical and nursing dissension, relationship between nurses and patients, lacking training and communication skills of terminal nursing and time deficiency of spiritual caring. These restrictions above will bring influences on decision of terminal patients and on satisfying their spiritual demands. Also it may cause physical, mental and spiritual powerlessness and sorrow on nursing personnel.

Methods

This study used narrative research design with purposive sampling of 5 part-time graduates from master class of nursing department. The narrative study was following Lieblich et al. narrative study process with Morgan narrative therapy steps [22,23]. The narrative therapy of cases who described mainstream stories and identified their negative events through the reading of their own stories. Cases gave their negative events nicknames, as the process of externalization; they also analyzed those negative events by determining when they start, the factors that influence them, and the effect on their lives. The cases also identified their turning point, which meant that there were critical points for them to transform. Finally, they learned how to find substitute stories as a coping mechanism whenever negative circumstances arose.

For studying samples, Musgrave et al. reviewed 19 literatures from America and Israel about the spiritual and caring attitude which impacts nurses in oncology and non- oncology department and those who in oncology department was easily to perceive comforts or troubles in spirits and better at providing spiritual caring [24]. The following inclusive criteria for this studying sampling included nurses who have 5 year or more experiences working in intensive, cancer or hospice units, were willing to sign informed consent of research participation for the audio interview, would like to share personal experience, could speak in Mandarin and Taiwanese and accept 60-90 minutes interviews.

This study has passed the review from Institution Review Board Committee of one hospital (FYH-IRB-104-06-01-A). Data were collected by basic information questionnaire and semi-structure guideline with interviewing twice by the researcher who has 13-year clinical nursing working experience and the training experiences of narrative, quantitative and spiritual research from August, 2015 to February, 2016. The second time of interviewing was assurance the data fit into the 4 principles of promoting width, coherence, insightfulness, parsimony. Data analysis was followed the model of “Category-Content” for narrative study [1].

Results

The five participants were women with age ranged from 28-41 years and 3 were single, 1 was married, and 1 has divorced. Their religion included Taoism, Buddhism, and Christianity, had no chronic diseases, and have family members with experiences of being hospitalized. They had worked in hospice and palliative units for 8.3 years on average, have a total working experience of 12.5 years, and had more than 100 hours of training on spiritual lessons. The results were divided into the two main spindles of the hospice caring and spiritual growth experiences. The themes of hospice caring experiences included doctors, nurses, and patients understand who as the most valuable, learning skills and assisting terminal with infinity price, and crossroads of hospice care. The themes of spiritual growth experiences included the clouds and dew where the life is, butterfly cocoon shed newborn, flying upwind and gas grand, and countenance generous dedication blessing. Following were the narrative descriptions for each theme.

The hospice caring experiences

Doctors, nurses, and patients understand who as the most valuable: “I have been in North Ireland for participating exchange student internship. In there, I found that nursing personnel are equal to the doctors and they can ask any questions to doctors. While in Taiwan, nursing personnel have lower status or even mean nothing. I saw respects in the communications among medical and nursing personnel in North Ireland. ” (Case E)

“There was a kid who had poor curative effect in chemotherapy. So he asked me: should I continue to do chemotherapy? I told him, you can think about it and talk to your parents. Then they decided to move to hospice units. I once contacted the parents in private; they told me that though they were reluctant at that moment, they felt comfortable because the child was rested in peace. Therefore I choose to support and respect the patients’ opinions, since this couple encouraged me to learn demands of patients” (Case T)

Learning skills and assisting terminal with infinity price

“The frustrating moment in my terminal nursing experiences is seeing families crying, because I didn’t know what to do. So I usually let other people to make comforts. This is related to experiences and environments. Used in general wards, I haven’t received any related training, so I usually escaped. I couldn’t feel same lost and sorrow of families and didn’t know how to comfort people. In hospice, it trains your speaking skills, and the training is integrated in daily behaviors. You can accumulate your experience every day. Now just by seeing the looking of families, I know what I should tell them. I want to have more interactions with patients and families. If picking one hour-talking for each patient, it will be overtime. To some nursing personnel, it’s time limitations instead of not unwilling to do this. So I tell the trainees that they should do more meaningful work in 8 hours during work” (Case M).

“Every patient has a unique story. Over half of patient families keep contacts with me. It’s not a nurse-patient relation; rather, it’s like friendship and bond with family. I need to company with families through patient’s death and do something to make them less helpless. It’s actually a sorrow-curing process. Patients had passed away for 3 or 4 years, while their families still remember me until now. That’s the value of my job. Though it’s tiresome, I love my job because the sense of achievement, which is not from the hospital but from my patients’ families. Also, my job can help me have a peaceful ending in future, since I can see a lot of death results of patients, I make reflection on myself and preparation for my own”(Case F).

Crossroads of hospice care

“The experience of terminal nursing grants me a lot of preparation. Making these preparations aims to not let my family reluctant to make decision. Since rescue or not are both suffering, I choose to live in the moment and not bother too much. In order to leave without regrets, I will try to complete anything I can do. Peace will head back to me and terminal preparation has prepared in anytime, since no one knows what is going to happen next second. Following the principle of no violation of medical ethics, I will be happy in my job. I think it’s happy to help others end peacefully” (Case F)

“In the clinical nursing of terminal patients, the behaviors of our hospital are quite different with our own opinions. Though patients signed the consent of do not resuscitate, doctors would still suggest family for rescue. I think it’s a violation of patient’s willing, so I am disappointed in hospice. I think administrators should support subordinate. Because I feel nursing personnel is humble and small now but nursing personnel should be equal and have mutual respect to doctors. I feel now in Taiwan, doctor is at the top level while nursing personnel is at grassroots, which is very disrespectful” (Case E).

“The experience of nursing terminal patients granted me a very subtle feeling about family relationship. I can see many different family relationships and find that people like to compare with each other. This problem is particularly obvious in clinics about in struggling of interest, which is very subtle and rare. Peace is in every aspect of life, only with informing and guiding. If you don’t follow it, I’ll respect you. Nursing personnel should insight and train for this ability” (Case M).

The spiritual growth experiences

The clouds and dew where the life is “After you contact with many terminal patients, you will value life. I think the point of improving the relationship between terminal patients and their family is to show piety in time. I don’t want any regrets in my life, so I will go for a talk with my father. I don’t know where his or my ending is, so I pay a lot of attention on my parent’s health. I want to help them living in a well-off condition. I used to think it costs too much, but after I contacted some patients, I changed my mind” (Case E).

“In ER, I always thought that life is impermanent, maybe you are here this second, and next second you’re gone. I used to think it’s unnecessary to save money and be so hard on myself. There is no reason that I can live today and can’t tomorrow. So why not cherish every moment you are living now? When I got paid, I used to plan for travelling and didn’t want to waste any of my time. My mother told me not to spend it all and I responded: seize the day” (Case A).

“When I saw people around me suffering from cancer, I want to live at the moment and do anything as long as I have a clear conscience on self and other people. If I die tomorrow, I will have no regrets since I live my life every day as the last day. In emergency and intensive units, I become open-minded since I have learned the sense of life and death. In mother’s home, people prefer to live in the moment. But my husband refuses to talk about it believing that it will bring misfortune. My experience in ER taught me to prepare ahead of time to avoid panic. The important point is leaving no regrets, which requires us treat every day as the last day to live a happy life and cherish the people, matters and things” (Case A).

Butterfly cocoon shed newborn

“When I was young, I talked with my mother about my troubles. I used to feel depression in my young age, because I didn’t know what to do and afraid of hurting people I care. After I grown up, I found my mother will worry about me, so I choose to talk with my brother. Usually I won’t talk about my pressures and suffer it to the limit, and then I will talk with my friends to release. When pressures are too much, I will do jogging to release. After jogging I will find another direction to adjusting” (Case E).

“Before I started this job, I barely had any frustrating feelings. After starting this job, I need to nurse terminal patients all the time. I release pressures by writing and walking. Walking can help me thinking through a lot of things. Because of my physical condition, I started to get used of walking which can promote metabolism. I face the pressure from colleagues. I used to be unable to accept critics directly from seniors and would ask back. At that time I was just starting this job, I was rigid and didn’t think I was wrong. Seniors might think I was in chicanery. When I coached freshmen seeing this kind of attitude, I then realized the feeling of seniors. Since characters differ, we may have different thoughts about things. Maybe I was too sensitive at that time and thought seniors were criticizing me. Now I realize that seniors are guiding and reminding you” (Case M).

Flying upwind and gas grand

“I keep an open mind in frustrating feelings, since I believe that all arrangements are the best arrangements, and then I’ll be released. Now when facing difficulties, I act first. Positive thinking can bring you power to believe that every difficulty has a chance. After suffering it must come with happiness. And everything will become better. Difficulty means challenge. There must be a result in everything and you just need to expect the result” (Case A).

“Difficulties you suffering are related with your personal positive thinking. When facing difficulties, you need to figure out solution on your own: I can fix it, just like moving a stone instead of escaping from it. I will not burden too many negative feelings on me. After crying I will fight with it. The attitude is from my home education. I’m not used to ask for help, instead I devote myself in resolving the problems. I won’t ask for resources. I handled all the things of divorce and custody of my child, by myself. The family situation at that time made me being strong as a woman. Until now I still appreciate the support from my patients and their families. They helped me went through those tough days and cured me. It’s the added values between me and my patients and their families” (Case F).

“When I have no idea about how to help terminal patients, I participate in advanced lessons of oncology and hospice department. I will bring knowledge back to my work, applying basic hospice nursing in clinics. Now I only expect health and safety in my life, nothing else matters. I become indifferent to fame and wealth now, trying my best only for a clear conscience on myself. Facing difficulties, maybe after crying or asking advises from the elders, I will make the appropriate decision by myself. I also watch online articles and encourage myself before the mirror, telling myself that you can do it. That will make me feel better” (Case T).

Countenance generous dedication blessing

“I used to follow the principle of doing things in black and white. Now I find many gray zones and realize that not everything can be answered with yes or no. now I know there should be no 100% certain answer, like I used to think hospice is just waiting to death 10 years ago, now I believe it’s more like to provide a good ending. Different times and backgrounds create different answers with different meanings. I have my own standards to do the judgment. While in gray zone, everyone has his own answer and I can accept it. The reasons of this changing are part from aging and part from work experiences. With these, I find different subject backgrounds. One thing may have many different answers and explanations from different people” (Case M).

“I will make some time for volunteer clinics, like domestic community screening or health promotion. Following with the dentists to some foreign countries with poor medical conditions for free clinics is the thing I can do, because I was from medical background, and my experiences can not only help my work also can help some other people. It helps me satisfied my psychological needs and also provides affirmation of my own values. The experience of pro bono service overseas makes me feel my life in Taiwan is happy and it also broadened my vision, becoming a part of my life experience” (Case F).

Discussion

The discussion was divided into the hospice caring and spiritual growth experiences. The hospice caring experiences found in this study were similar and different from the literature review which identified children and adult terminal care experiences. The similarity was emphasized on the communication between health care professionals and patients, and facing the dilemma of decision making about palliative care and DNR [9,16,10,20]. Also this study found the priceless of leaning skills to assist terminal patients as similar to the findings from 28 nurses in oncology department of China identifying the experiences of self-examination of life and death and trained advantages [21].

The difference was the literature mentioned the providing faith response resources [13] and caring of bereavement and sorrow for the family of terminal patients [10,21]. Additionally, the literature proposed the spiritual caring interventions providing for the terminal patients including love, easing on mind, value pursuit in life, kind faith and faith comfort, integrate differences in faith and cultures, the coordination of different customs, relationships with peers, and satisfying the spiritual demands from patients with arts, praying and other methods [11,18,17,21]. Furthermore, two essential spiritual caring studies were provided by 20 muslin nurses as finding the true God, life mission and goals, believing in rebirth, improving communication of spiritual cares, going beyond life [14] and by 83 Sweden nurses as assisting the terminal patients transformed from the suffering misery into hope experiences [15,22].

The spiritual growth experiences in this study included the clouds and dew where the life is, butterfly cocoon shed newborn, flying upwind and gas grand, and countenance generous dedication blessing. Instead of being positive experiences of spiritual growth; however, Noble and Jones identified 7 UK oncology nurses complained the barriers of providing spiritual care including the different definition of spirit, spiritual strategy, lacking spiritual care and communication training, and deficiency of time [12]. Liu and Chiang also explored experiences of 7 oncology Taiwanese nurses who cared the terminal patients and found themselves as weakness and being- with –others [20]. As Lee et al. explored spiritual meaning from 11 nurses in intensive care unit of Taiwan and identified the spiritual meaning, personal spiritual essence, and interpersonal interaction [19]. It seems that the spiritual needs and demands of nurses should be reviewed and nurtured initially and later on the spiritual care training could be provided for them to learn the spiritual care skills.

Additionally, the difference of findings in this study from the literature is because the majority of literature was used the qualitative research design as phenomenology or interpreting method. However, this study used narrative study by Morgan narrative therapy steps in the process of transforming from negative into alternative stories through the different point of view [23]. In other words, nurses in this study were not only being interviewed their hospice caring experiences, but also identified the spiritual growth process through their narrative transcriptions. Instead of being a research, this study also could consider the samples to be transformed and empowered through the process of looking at their own old stories in a new vision; in turn, they would have the re-born feelings with the refresh life for their career.

Conclusion

This study explored the spiritual growth experiences of nurses caring for terminally ill patients. Using the method of narrative study, we interviewed five nurses who used to care for terminally ill patients, and followed a semi-structured guideline for data collection. This study has passed the review from Institution Review Board Committee of one hospital (FYH-IRB-104-06-01-A) and data were collected from August, 2015 to February, 2016. The participants were interviewed twice individually and the second time of interviewing was assurance the data fit into the 4 principles of promoting width, coherence, insightfulness, parsimony. Data analysis was followed the model of “category- content” for narrative study [1].

The five participants were women with age ranged from 28-41 years, their religion included Taoism, Buddhism, and Christianity. They had worked in hospice and palliative units for 8.3 years on average, and had more than 100 hours of training on spiritual lessons. The results were divided into the two main spindles of the hospice caring and spiritual growth experiences. The themes of hospice caring experiences included Doctors, nurses, and patients understand who as the most valuable, Learning skills and assisting terminal with infinity price, and Crossroads of hospice care. The themes of spiritual growth experiences included the clouds and dew where the life is, butterfly cocoon shed newborn, flying upwind and gas grand, and countenance generous dedication blessing. The results could provide a positive outlook for nurses in promoting their spiritual growth and transformation and in continually disseminating the energetic aspects of nursing. Following is the concept map for the spiritual growth experiences from five studying samples (Figure 1).

Summary, holistic nursing is a process of nursing terminal patients, and nursing personnel is the important part which provides nursing and cares. However, while nursing terminal patients, nursing personnel may face weak spirit problems. These problems can be resolved by narrative to improve the spiritual development, including perceiving self-spirits, realizing life meanings and values, the cognition and attitudes of spirits through understanding, analysis and establishing their own stories. This further inspires comprehending touches and conduct spontaneous internal change on spirits, and improving nurse-patient relationship and the ability of spiritual caring, as well as promoting spiritual comfort of nursing personnel and assisting self- development of spirits. Nursing personnel then are able to aware of their mission, highlighting the brilliances of life.

Suggestions

The researchers proposed some recommendations based on the studying findings. In the clinics, hospice lessons and the spiritual development group of health care professionals should be listed in regular in-service education. For the patient’s application, it could apply narrative process on patients and health care professionals to help them find their life meanings and values. For nursing education, it is suggested to have communication training lesson of hospice care and spirit to improve nursing ability for terminal patients.

Acknowledgement

Finally, here comes a conclusion of this study. It should be joyful for harvesting, however the principal researcher has no a grain of joy. One (case F) of the subjects in this study suddenly passed away of an illness, which made me shock and in great grief. When I was informed of her terminal illness, the researcher prayed for her several times and visited her with the professor, hoping the God would help her. When I first saw her, she was a quiet and introverted girl. After learning that she had accepted military training, the researcher felt admiration for her. Since my father was served in military and I know the hardship in military, the researcher always held a respect as the modern Mulan (a female army hero from the Chinese history) to subject. After her passed away, the researcher cannot finish this study for many days, for the hardship gave by the event. So the researcher chose narrative to comfort. In addition to pray to the God, the researcher also narrated with family members and sisters in church. The researcher felt released after a few days and realized that the spiritual development of this subject should be presented as soon as possible to make her contribution worthy. The following concept map is for case F’s spiritual growing process after caring the terminally ill patients to remember her strong personality and spirituality (Figure 2).

References

1. Lieblich A, Mashiach RT, Zilber T (1998) Narrative Research Reading, Analysis, and Interpretation. Water Stone Publishers, Chiayi City, Taiwan
2. Tu MS (2008) Clinical Application of Spiritual Care. J Intern Med Taiwan 19: 318-324.
3. Lin YH, Liu SH, Chen CH (2008) Spiritual Care in Nursing Practice. J Nurs 55: 69-74.
4. Lan KI, Saunders SM (2007) Introduction to the special issue on spirituality and psychotherapy. J Clin Psychol 63: 903-907.
5. Lan YH, Chao SY, Chen SL, Chuang CM, Kuo JM (2007) An Exploration of the Non-Hospice Care Unite Nursing Staff’s Cognition of Hospice Care, Fear of Death and Emotional Distress. Taiwan J Hosp Palliat Care, 12: 156-171.
6. Cole L (2003) Say when end-of-life decisions in PICU. J Pediatr Nurs 19: 138-143.
7. Wu HF, Hsiao YC (2009) A Study of the Correlation between the Spiritual Health Status and Spiritual Care Abilities of Nurses. J Nurs Healthcare Res, 5: 68-78.
8. Riessman CK (2003) Narrative Analysis. Wu-Nan Book Inc, Taipei City, Taiwan.
9. Chen YH, Chen YC, Lo LH, Lin DT, Wang JD (2008) Acute Pediatric Nursing Barriers of Caring for Terminally Ill Children. Chang Gung Nursing 19: 450-460.
10. Huang YP, Chen Y C, Chen YH (2009) The Experience of Difficulties of Pediatric Nurses Caring for Dying Children in non-palliative Care Units. Cheng Ching Med J 5: 30-38.
11. Belcher A, Griffiths M (2005) The spiritual care perspectives and practices of hospice nurses. J Hosp Palliat Nurs, 7: 271-279.
12. Noble A, Jones C (2010) Getting it right: oncology nurses’ understanding of spirituality. Int J Palliat Nurs 16: 565-569.
13. Ekedahl M, Wengstrom Y (2010) Caritas, spirituality and religiosity in nurses’ coping. Eur J Cancer Care 19: 530-537.
14. Khorami Markani A, Yaghmaei F, Fard MK (2013) Spirituality as experienced by Muslim oncology nurses in Iran. Br J Nurs 22: S22-S28.
15. Browall M, Henoch I, Melin-Johansson C, Strang S, Danielson E (2014) Existential encounters: Nurses' descriptions of critical incidents in end-of-life cancer care. Eur J Oncol Nurs 18: 636-644.
16. Decker K, Lee S, Morphet J (2015) The experiences of emergency nurses in providing end-of-life care to patients in the emergency department. Australas Emerg Nurs J 18: 68-74.
17. Tsai SL, Lin SL, Lin HL, Mu PF (2002) The Living Experience of the Novice Oncology Nurses for Cancer Patient Care. VGH Nursing, 19: 153-167.
18. Chang LJ, Wang HC, Chen YF (2006) A Qualitative Exploration of the Recognition of Spiritual Care Carried out by Hospice Nurses. J Med Educ 10: 62-69.
19. Lee JT, Chen SM, Chou CC, Ku YL (2013) Exploring Spiritual Essence of ICU Nurses. Chang Gung Nursing, 24: 366-378. 
20. Liu YC, Chiang HH (2014) The Practical Wisdom Gained in the Provision of End-of-Life Care. J Nurs, 61: 33-42.
21. Zheng RS, Guo QH, Dong FQ, Owens RG (2015) Chinese oncology nurses’experience on caring for dying patients who are on their final days: A qualitative study. Int J Nurs Stud 52: 288-296.
22. Lieblich A, Mashiach RT, Zilber T (1998) Narrative Research Reading, Analysis, and Interpretation. Water Stone Publishers, Chiayi City, Taiwan
23. Morgan A (2008) What is narrative therapy? An easy to read introduction. Psy Garden Publishing Company, Taipei city, Taiwan.
24. Musgrave CF, McFarlane EA (2003) Oncology and non-oncology nurses’ spiritual well-being and attitudes toward spiritual care: A literature review. Oncol Nurs Forum 30: 523-527.