Abstract
Background:
Oncology and palliative care staff frequently encounter death yet often lack structured opportunities for reflection following these experiences.
Objectives:
This study asked: How can we develop and implement a reflective practice program for oncology and palliative care staff to support them with patient death? Reflective practice is recognized as a valuable tool to support staff well-being; however, there is limited literature describing how such interventions are implemented in the hospital setting.
Methods:
A participatory insider-action research approach was undertaken to codevelop a reflective practice program. A multidisciplinary Action Research Group collaborated through a series of meetings to codesign the program. The data consisted of contemporaneous notes capturing group discussions on what was needed to develop the program. Thematic analysis was used to identify key ideas and patterns that emerged from these discussions, enabling the group to identify factors required to develop a format to support guided reflection.
Results:
Key themes included the importance of language, timing and location, facilitation and structure, and case selection. The final outcome was a practical, semistructured format for reflective practice sessions for staff to follow as a framework to support reflection and emotional processing in response to patient death.
Conclusions:
Using an insider action research approach, this staff-led project offers an adaptable framework for structured reflection in acute hospital settings and represents an important initial step towards embedding reflective practice into the culture of health care.
Keywords
Key Message
Oncology and palliative care staff in an Irish acute hospital collaboratively developed a structured reflective practice program to support coping with patient death. Using insider-action research, this pilot study demonstrates a feasible, staff-led approach to embedding reflective practice into routine clinical practice.
Introduction
Health care workers in oncology and palliative care are frequently confronted with the death of patients, a regular aspect of their work, which can have profound emotional consequences.
Hospitals remain the most common place of death in Ireland, with the General Register Office noting 42.9% of deaths recorded during the 2023 National End of Life Survey occurred in the acute hospital setting. 1 These cumulative effects of repeated losses can contribute to compassion fatigue and burnout. 2 In hospital settings, staff often develop meaningful relationships with patients during prolonged periods of care. Papadatou recognized this loss of a relationship with a patient with whom one has shared part of their journey as a distinct form of grief health care workers face. 3 Care of the dying patient often takes place in high-pressure settings within the acute hospital system. Within a specialist inpatient ward in an Irish tertiary hospital, where this action research (AR) project is set, staff manage up to 28 oncology and palliative care patients and their families each day, navigating complex clinical needs along with the emotional weight of end-of-life care. Despite these challenges, the fast-paced hospital environment often requires staff to move quickly from one patient to the next. This lack of time to process grief can leave staff feeling unsupported, as they may be unable to adequately reconcile the loss before moving on to the next patient. During the COVID-19 pandemic, Rahmani et al. found that health care providers were at risk of complicated grief reactions due to frequent exposure to patient death, 4 with staff citing a lack of time to process the deaths as a factor leading to unresolved grief. Without structured opportunities to acknowledge loss, grief may remain unresolved within health care teams. Reflective practice can offer one such opportunity.
Reflection is an intentional process of questioning assumptions and integrating new understanding into practice. 5 Reflective sessions following patient deaths have been shown to support psychological well-being and promote a sense of solidarity among health care professionals. 6,7 This aligns with findings from a study on hospice volunteers by Coleman et al., which revealed the importance of participants feeling connected to other volunteers, as peers could offer another layer of support when dealing with challenging situations. 8 Organizationally, supporting staff to reflect aligns with broader goals of enhancing patient safety and care quality, as it is recognized that employees who are allowed time to reflect and develop will make significant contributions to patient well-being and safety. 9
This project was informed by established theories of reflective practice, including Schön’s concept of reflection on-action, 10 and it asked: How can we develop and implement a reflective practice program for oncology and palliative care staff in order to support staff with patient death? While evidence supports the benefits of reflective practice for staff, little research explores the process of developing and implementing a reflective practice program in the acute hospital setting.
Materials and Methods
Design
A definition of AR is put forward by Coghlan and Shani, who describe it as “an emergent inquiry process in which applied behavioral science knowledge is integrated with existing organizational knowledge and applied to address real organizational issues.” 11 AR differs from other research methodologies in that it simultaneously generates knowledge while driving change in real-time, with data emerging through iterative cycles of action and reflection. It aims to create immediate, practical improvements while also contributing to broader knowledge in the area. 12 This study adopted an insider AR approach, whereby the researcher, as a member of the organization, undertakes the project along with their usual role. 13 This dual role enables insight into the organizational culture and facilitates engagement with colleagues, fostering collaborative change from within. The participatory nature of AR makes it suited to bringing about change in the health care setting, where staff engagement is critical to developing sustainable changes in practice. 14 Kotter’s eight-step model 15 offered a practical, step-by-step approach to initiating and sustaining meaningful change within organizations, making it well-suited to the introduction of reflective practices in the hospital setting. 16 Reflexivity was crucial, requiring examination of potential biases arising from the researcher’s dual clinical and research role. The perspectives of the multidisciplinary team within the AR Group helped mitigate blind spots and strengthen interpretive rigor. Ethical considerations included managing role duality as an insider action researcher and minimizing any perceived pressure to participate. Participation was voluntary, with written informed consent obtained and ongoing consent reaffirmed verbally at each AR Group meeting, consistent with a covenantal approach to ethics in AR. 17 While anonymity was not feasible in this transparent, group-based setting, psychological safety was prioritized through clear expectations of respect, discretion, and confidentiality within the group. Ethical approval for this study was obtained from the Galway Clinical Research Ethics Committee (approval granted on January 2, 2025—Ref: C.A. 3324).
Setting and participants
The study was conducted on an acute oncology and palliative care ward in an Irish Model 4 hospital. A multidisciplinary AR Group was formed to codesign and refine a structured reflective practice program. Participants were selected through purposive sampling, the deliberate selection of participants most likely to yield appropriate and useful information. 18 The objective was to involve experienced staff who were motivated to engage in the development of a reflective practice program as a method of supporting colleagues with patient death. Inclusion criteria required that participants be currently working in oncology or palliative care on the designated hospital ward and have at least one year in that setting. This threshold was chosen to ensure that participants had sufficient familiarity with the clinical and emotional demands of the ward environment, team dynamics, and the realities of care of the dying patient. Those invited included clinical nurse specialists in palliative care, clinical nurse managers, medical social workers (MSWs), and registrars in palliative medicine. Participation was voluntary, and no formal demographic data were collected, consistent with the project’s developmental focus. In total, eight staff were invited to participate, with six total staff taking part in the AR Group. The numbers chosen to participate in the group were in keeping with evidence showing that the ideal size of a focus group is between 5 and 10 participants. 19 The breakdown of the final six AR Group members was as follows: One palliative medicine registrar, one clinical nurse specialist in palliative care, two clinical nurse managers on the oncology and palliative care ward, and two senior MSWs working in palliative care and oncology. Several AR Group members had prior experience with similar reflective interventions in other hospital settings, and their valuable insights informed practical planning around timing, logistics, and facilitation. The AR Group met four times in total, with two meetings to discuss practicalities and program design, followed by a trial reflective session on the ward, after which the group held a final meeting to reflect on the trial and agree upon refinements. Feasibility was supported by the project’s emergence from informal discussions with colleagues expressing a desire for structured reflection on challenging cases, along with sustained voluntary staff engagement in the AR Group and staff attendance at the trial session.
Data collection and analysis
Data for this project consisted of handwritten contemporaneous notes of pertinent discussion points that arose during the AR Group meetings. Rather than a verbatim transcript of the entire discussion, the notes captured the main consensus points identified by the group. Audio recording was not used in order to support psychological safety and candid discussion. Themes were generated from these notes using Braun and Clarke’s six-phase approach to thematic analysis. 20 Iterative cycles of discussion and refinement within the AR Group enabled the identification and clarification of key themes. At the end of each meeting, participants were asked to review the notes to ensure they provided an accurate reflection of the topics discussed.
Results
Analysis identified five key themes that informed the development of the reflective practice program: Language and framing; timing and location; facilitation and structure; case selection and relevance; and emotional value.
Language and framing: Language was seen as critical in shaping staff perception of the sessions. Participants preferred the term “reflective session” to “debrief,” as the latter was felt to imply error or incident. Psychological safety within the sessions was seen as essential, with emphasis placed on avoiding blame and establishing clear ground rules to promote respectful and supportive discussion. Timing and location: Sessions lasting approximately 30 minutes were considered optimal; shorter sessions were deemed insufficient, while 45-minute sessions were impractical within ward demands. Coinciding the sessions with the afternoon “Safety Pause” (a brief meeting mid-shift to identify patient safety issues
21
) anchored sessions to a natural break in the workflow. The ward office was felt to be a suitable venue. The AR Group recommended sessions should be held no sooner than two weeks after the death had occurred to allow staff time for personal reflection and processing before participating in a group setting. Holding sessions earlier than two weeks post-death may be helpful for some team members; however, it was not preferred in this setting. This could be trailed in future iterations of the project. Facilitation and structure: Facilitation was viewed as central to success. There was agreement that a facilitator was needed to guide discussion and keep sessions focused and constructive. Ideally, this person would be neutral and not directly involved in the case being discussed to avoid bias. The ward MSWs were identified as most suited, given their communication skills and group facilitation experience. Psychological safety was supported through the establishment of clear ground rules at the outset: Confidentiality with what was shared and a nonjudgmental approach. Sessions followed a semistructured format: Opening with a brief case summary, discussing what went well, exploring what could have been done differently, and closing by acknowledging the work done by staff. A 10-minute warning before the end of the session allowed final contributions and ensured the session kept to time. To maintain a comfortable environment and ensure all could participate, attendance was capped at 10 participants. In the event participants became distressed during the session, facilitators were prepared to pause the session, check in with the individual concerned, and, where appropriate, signpost available supports. Case selection and relevance. Cases involving younger patients, long or complex admissions, and difficult deaths were prioritized. Staff expressed a preference for reflecting on patients well known to the team over the duration of their illness, as these were felt to be particularly difficult emotionally. To ensure relevance, it was felt that staff should have a voice in choosing future cases to discuss, with an anonymous suggestion box proposed as one method to do this. Emotional value. Participants described the sessions as valuable opportunities to pause, reflect on the patient as a person, and honor their memory. Symbolic gestures such as lighting a candle or holding a moment of silence were proposed to reinforce the reflective atmosphere.
Drawing on these themes, the AR Group codeveloped a practical, semistructured reflective session format designed to help guide staff through the reflective process (see Supplementary Data).
Conclusion
This insider-AR project explored the question—how can we develop and implement a reflective practice program for oncology and palliative care staff to support them in coping with patient death? Through a collaborative, staff-led approach, the program has been cocreated by the staff who stand to benefit from it. The program was shaped over time through a series of iterative group discussions, with a trial session and subsequent feedback. Formal pre- and postintervention evaluation of staff was beyond the scope of this project. Consistent with AR methodology, learning arose through collaborative development and refinement of the program, rather than through outcome measurement. However, future AR cycles could aim to examine the intervention’s impact and outcomes for staff. The final outcome highlights the value in engaging staff to take part in designing an intervention that supports their real-world needs. The project has contributed an adaptable model for structured reflection in the acute hospital setting and underscores the importance of acknowledging the emotional toll of caring for patients at the end of life. This is an important step towards embedding reflective practice into the culture of health care, with potential for future AR cycles to build on this work even more, involving greater numbers of staff and further evaluating the intervention’s effectiveness. By recognizing the human experience of loss among health care workers, reflective practice has the potential to enhance team cohesion and support the resilience of those who care for patients in the final stages of life.
Footnotes
Acknowledgments
The author would like to sincerely thank the staff at the Irish Hospice Foundation for their support and guidance throughout this master’s program. She would like to thank her supervisor, Associate Professor Mary Casey, whose expertise was invaluable. Finally, her heartfelt thanks goes to the staff who were a part of this project. Their generosity in sharing their time, experience, and knowledge greatly enriched this work.
Author’s Contributions
G.K.: Conceptualization, study design and methodology, data collection, data analysis, interpretation, article drafting, and final approval. She has read and approved the final version of this article.
Author Disclosure Statement
The author, G.K., declares that there are no conflicts of interest relevant to the content of this article. The research was conducted as part of the fulfilment of the MSc Loss & Bereavement in association with the Royal College of Surgeons, Ireland, and the Irish Hospice Foundation. G.K. confirms that this article represents original work based on my MSc thesis and has not been published previously nor is it under consideration elsewhere. G.K. confirms that all data were collected, analyzed, and interpreted by her as part of her postgraduate research.
Funding Information
This project received no external funding.
Supplemental Material
References
Supplementary Material
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