palliative and supportive care

The provision of end-of-life care by medical-surgicalnurses working in acute care: A literature review

JUDITH GAGNON M.SC.N, R.N., AND WENDY DUGGLEBY, PH.D., R.N., A.O.C.N.Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alberta, Canada

(RECEIVED May 1, 2013; ACCEPTED May 27, 2013)

ABSTRACT

Objective: Caring for terminally ill patients is complex, stressful, and at times distressing fornurses. Acute care hospitals continue to be the predominant place of death for terminally illpatients in mostWestern countries. The objective of the present literature review was to exploreand gain an in-depth understanding of the experience of providing end-of-life (EOL) care bymedical-surgical RNs working in acute care hospitals, to identify knowledge gaps, and torecommend future research.Method: A comprehensive literature review was conducted using the following electronic

databases: CINAHL, MEDLINE, and PsyInfo (from 1992 to October 2012).Results: The findings from the 16 reviewed studies suggest that nurses felt a strong

commitment to help terminally ill patients experience a good death. Nurses reported feelingdeeply rewarded and privileged to share the EOL experience with patients/families.Organizational and individual factors influenced nurses experience. Important challengeswere associated with managing the divergent needs of a mixed patient load (i.e., curative andpalliative care patients) in a biomedical culture of care that is heavily oriented toward cure andrecovery. In this culture, nurses emotional work and ideals of good EOL care are often notrecognized and supported.Significance of results:Managerial and organizational support that recognize the centrality of

emotional work nurses provide to dying patients is needed. More research exploring ways toimprove communication among nurses and medical colleagues is essential. Finally, a criticalexamination of the ideological assumptions guiding nurses practice of EOL care within thecontext of acute care is recommended to help reveal their powerful influence in shaping nursesoverall understanding and experience of EOL care.

KEYWORDS: End of life, Medical nurses, Surgical nurses, Acute care, Hospital

INTRODUCTION

Acute care hospitals continue to be the predominantplace of death for terminally ill patients in mostWestern countries (Jacobs et al., 2002; Sorensen &Iedema, 2011), and nurses are key players in the pro-vision of end-of-life (EOL) care. Considering theircontinued presence at the bedside, nurses are expec-ted to care holistically for terminally ill patients/families while they adjust to and live through the tra-jectory of the terminal illness (Fitzgerald, 2007).

However, the high-tech acute care environment ofhospitals has been recognized as suboptimal forEOL care (Jacobs et al., 2002; Sorensen & Iedma,2011), and in such a context a comprehensive ap-proach to care can be very difficult for nurses to ac-complish due to: (a) the very fast pace of theenvironment, (b) the biomedical culture focused onactive treatment and cure (Summer & Townsend-Rocchiccioli, 2003), and (c) the cultural reluctanceto discuss sensitive issues surrounding dying andthe death itself (Willard & Luker, 2006; OGorman,1998). In that regard, the perceived cultural normsin acute care settings can have a strong influenceon staff behaviors, attitudes, and beliefs toward dy-ing patients (Wilson & Kirshbaum, 2011), even

Address correspondence and reprint requests to: Judith Gag-non, Faculty of Nursing, Level 3, Edmonton Clinic Health Acad-emy, University of Alberta, 11405 87th Avenue, Edmonton,Alberta, Canada T6G 1C9. E-mail: [email protected]

Palliative and Supportive Care (2014), 12, 393408.# Cambridge University Press, 2013 1478-9515/13 $20.00doi:10.1017/S1478951513000965

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more so when these norms ignore the consequencesand suffering that caring for dying individuals cancreate in healthcare professionals (Willard & Luker,2006).

In a literature review focused on the effect of deathon nursing staff, Wilson and Kirshbaum (2011) notedthat much of the knowledge development on EOLcare reports on the experience of patients and theirrelatives. Furthermore, research on EOL has mostlyexplored the experience of nurses working on speci-alty units, such as oncology, palliative care, andcritical care (Wilson & Kirshbaum, 2011). The medi-cal-surgical nurses (or generalist nurses) representan important group of nurses involved in the pro-vision of EOL, yet no review to date has exploredsuch specific experience in providing EOL carewithin an acute care environment. According to theCanadian Association of Medical Surgical Nursing,medical-surgical nurses are considered the largestgroup of practicing nurses and have been referredto as the foundation of our healthcare system(CAMSN, 2008). Considering the valuable role thesenurses play in supporting many of the dying patientsin our acute healthcare institutions, the aim of thisliterature review is to explore and gain an in-depthunderstanding of this experience, identify knowledgegaps, and recommend future research. We will at-tempt to answer the following questions: How is theexperience of providing EOL care described by nur-ses? What are potential factors that influence nursesresponses and adjustment to provision of EOL care?What future research is needed in this area?

METHODS

Search Criteria

Inclusion Criteria

The sample inclusion criteria for the review were asfollows. Published and peer-reviewed articles of em-pirical research reporting the experience and/or per-ceptions of acute care nurses regarding provision ofEOL care in an acute care hospital, in a context otherthan critical intensive care units. Studies were lim-ited to adult acute care where medical-surgical nur-ses were on staff. Studies including other areas ofnursing practice or other healthcare professionalsperceptions and experiences were considered aslong as the data attributed to the medical-surgicalnurses were clearly identifiable. All study designswere included, based on the belief that combingthrough data from different types of research couldpotentially increase the depth and breadth of ourconclusions (Whittemore, 2005). Studies that repor-

ted exclusively on critical care and ICUnurses, oncol-ogy, or palliative care nurses were excluded.

Literature Search

The first author conducted the literature searchduring September 2012 using the CINAHL, MED-LINE, and PsyInfo databases, from 1992 to October2012. The search criteria included the terms end-of-life, palliative care, terminal care, death and dying,nurs*, medical-surgical, acute care, hospita*, andtertiary care. Reference lists of key papers were re-viewed to identify additional relevant references.

In all, 650 references were found and reviewed,considering the title and abstract first. A total of 16studies met the inclusion criterion. Studies werefrom developed countries and included the UnitedStates (4), Canada (2), United Kingdom (2), Sweden(2), Ireland (1), Australia (3), Singapore (1), andJapan (1). In all but two studies (Davidson et al.,2003; Thacker, 2008), the authors specified that themajority of participants were female. The age of thenurses and years of experience varied across studies,but this information was not always available. Theincluded studies employed qualitative designs (9),mixed methods (1), and quantitative designs (6)(see Table 1; also marked with an asterisk in the re-ference list below). Two separate publications repor-ted findings from one original study (Hopkinsonet al., 2005; Thompson et al., 2006b). Most studiesfocused exclusively on registered nurses (RNs). Twoquantitative studies also included nurse participantsfrom other areas of practice: oncology, cardiology, pul-monary, and cardiac care (Cramer et al., 2003;Thacker, 2008). Thesewere included since nurses ex-perience according to area of practice was identifi-able. One study combined data from nurseparticipants working in the community, in homecare, and on medical-surgical units in a hospital(Wallerstedt&Andershed, 2007). The specific experi-ence of medical-surgical nurses was not singled out,but the authors suggested that their findings reflecta commonality across settings. One study also inclu-ded nurse students and support workers who experi-enced EOL care onmedical-surgical wards (Clarke &Ross, 2006), but, again, specific comments from thosenurses were identifiable.

Analysis

This narrative review was conducted as per the fol-lowing steps: (1) identification of the topic, (2) searchof the literature, and (3) reading and critique of thesources, followed by (4) an in-depth analysis of thesources to identify systematically the main recur-rent and/or most important (based on the reviewquestions) themes and/or concepts across multiple

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Table 1. Summary of the studies included in the review

Authors/Year/Country Purpose/Study Design/Method Sample/Setting Findings/Results Themes

Smyth & Allen(2011)Australia

Purpose: To explore and describehow nurses define spiritualityand incorporate spiritual careinto their clinical practiceStudy design: Mixed methods;explanatory descriptive design

Sample:N 16 nursesFemale: N 14RN: N 12Enrolled: N 4YOP [38 years]: N 7YOP [2037 years]: N 9Faith: N/ASetting: Regional ruralhospital; acute care medicalward

Spirituality is an essential part of being anurse.

It is incorporated into the care but followsa less prescriptive approach; listening;observing and communicating.

Organizational constraints lack ofprivacy, hamper spiritual care.

Mix staff; differing idea of spirituality.Nurses experienced tensions from a focuson cure and acute care vs. the spiritualneeds of dying patients.

Organizational constraints:Biomedical culture of careNurse factors:Clinical experience

Johansson &Lindahl(2012)Sweden

Purpose: To describe the meaningsof generalist RNs experiences ofcaring for palliative care patientson general wards in hospital

Study design: QUALPhenomenology(Ricoeurs philosophy)

Method: Narrative approach

Sample: N 8Female RNsYOP: [332 years]Faith: N/ASetting:Two hospitalsMedical/surgical care

Seven themes:(1) Being grateful to be able to share inthe end of anothers life(2) Being touched by physical andexistential meaning(3) To exist in place and space(4) To give and receive energy(5) Being open in relation to patientsand colleagues(6) Being in embodied knowledge(7) Time that does not exist

By being an embodied knowledge nursesreferred to the intuitive quietknowledge within the nurses thatoperates as nurses are moving betweenrooms, back and forth between bothworlds (curative and palliative patient)& within the nurse. Spoke of atransformation & transition withinnurses.

Organizational factors:Constraints of time & mixload of patients

Nurse factors: Experience

Bjarnason(2010)ReligionUnitedStates

Purpose: to explore influence ofhealthcare providers religiosityon the care they deliver topatients

Study design: exploratoryquantitative studyMethod: Cross-sectional survey

Sample: N 494 RNFemale: N/AYOP: 2 years +Faith: N/AEducation: N/ASetting: Medical-surgicalacute care hospitals

Religiosity may be influencing hownurses address EOL discussion withpatients and what nurse may beavoiding based on her religion.

Nurse personal factor:Religiosity

Continued

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Table 1. Continued


Roche-Fahy &Dowling(2009)Ireland

Purpose: To explore the livedexperience of nurses who providecomfort to palliative care patientsin acute setting in small urbanhospital

Study design: qualitativeGadamerian hermeneuticphenomenology

Sample: N 17Female RNsEd: n/aYOP: 740 yearsFaith: N/AEducation: N/A

Four major themes (with subthemes).Time (privacy, place of care, space, anddignity).

Emotional cost to the nurse: emotionallabor engagement and detachment;advocacy.

Holistic approach in the provision ofcomfort (attending to spiritual, familyand physical needs).

Role of education and expert team inproviding comfort (communicationskills and palliative care teaminvolvement).

Organizational constraints:Biomedical culture of care.

Rice et al.(2008)UnitedStates

Purpose: To determine theprevalence of moral distress inmedical-surgical nursesStudy design: Quantitativeprospective cross-sectionalsurvey (response rate: 92%)

Sample: N 260 RNsFemale: n/aAge: 2161 years; median: 34years

YOP: median 6Faith: N/AEd:Diploma nurses: 29%BScN: 62%MN: 4%Setting:Adult tertiary care hospital

Moral distress was uniformly high acrossthe following six categories: (1)Physician practice, fear andincompetence; (2) Nursing practice:lack of experience and staffing; (3)Institutional factors (time); (4) Futilecare; (5) Deception; (6) Euthanasia.

Organizational constraints:Biomedical culture of care;communication andcollaboration with MD

Thacker(2008)UnitedStates

Purpose: To reveal acute carenurses perceptions of advocacybehaviors in EOL nursingpracticeExamining difference betweennovice experienced and expertnurses

Study design: Qualitativecomparative descriptive design(response rate: 33%)

Sample: N 317Age (n 305): 2073 years

Faith: N/AEd:Diploma nurse 47.1%BScN 21.2%

Setting:Three regional hospitals inmoderately sized urbanareasMed/Surg: 47.5%Critical care:23,9 %

Significant difference between novice,experienced and expert nurses inadvocacy education; area of practice;primary employee status andeducational level.

Three most frequent barriers commonacross to advocacy: (a) Physician; (b)Patients and family; (c) Fear ofspeaking up.

Nurses also reported barriers to EOLnursing practice in terms the followingcategories: a lack of communication;lack of knowledge; lack of time; lack ofhospital support.

Biomedical culture of care;collaboration andcommunication withfamilies and with MDNurse factors: Professionalexperience

Continued

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Table 1. Continued


Yin et al.(2007)Singapore

Purpose: To explore the relationshipamong demographic variablesand nurses attitudes toward thedying patients

Study design:Quantitative descriptiveMethod: Survey (response rate:77.9%)

Sample: N 96 NursesRNs 71.9 %Female 94,8%

Age: 1829 years 79.2%YOP N/AFaith: Christian 11.7%Buddhist 24.0%Muslim 20.8%Ethnicity N/ASetting: General surgical wardand medical oncology wardwithin same hospital inSingapore

Staff from both wards felt exhaustedtaking care of dying patients; bothreported feeling of helplessness.Caring for dying patients enhancereflection about life and death andmake them treasure life more.

Significant difference: RN staff workingin general surgical floor were 4.49times more likely to feel frightentoward taking care of dying patients(p 0.006); oncology staff more likelyto think of their own mortality ascompared to surgical nurses.

Religion: Buddhists felt more fulfilledthan Christians.

Organizational constraintsNurses factors: Religion;professional and personalexperience

Wallerstedt &Andershed(2007)Sweden

Purpose: To describe nursesexperiences in caring for gravelyill and dying patients outsidespecial palliative care settingsStudy design:Qualitative/phenomenology

Sample: 9 RNsFemale: N/AAge: 3065 yearsYOP: 1039 yearsFaith: N/ASetting: Home carecommunity & medical-surgical ward

Gap between ambition (ideal) and reality.Nurses felt a sense of responsibility toensure dying patients good death.

Cooperation among team members wasessential to good EOL care. Doctorsinsecurity affects cooperation; doctorsrelations are more demanding.Nurses reported that EOL careprovided greater insight about life;provided them with an opportunity togive to patient; to care for the wholeperson; allowed for personal growthand happiness/

Nurses reported forbidden feelings suchas: feeling of inadequacy; frustration;sorrow; loss & no longer having thestrength to cope.Nurses reported little understandingfor the work commitment and theirphysical and mental health in suchculture of care.

Organizational constraints:Biomedical culture of care;communication andcollaboration with MD.

Nurse factor: Clinicalexperience

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Table 1. Continued


Clarke & Ross(2006)UnitedKingdom

Purpose: To explore nursesperceptions and experiencesregarding listening and talking toding older people about issuesrelating to the EOL

Study design:QUALMethod: Focus groups and one-one interviews

Sample: N 24Age: N/AFaith: N/AMedical wards:RNs: N 11Student nurse: N 1Support workers: N 2

Palliative care ward:Student nurse: N 3Support workers: N 3Setting:Medical wards: n 2Palliative care ward: n 1

Factors influencing nursescommunication with older peopleincluded: (1) Nurses perceptions andexperiences of talking and listening toolder people; (2) Learning from othermembers of the multi-professionalteam; (3) Environmental andorganizational constraints such astime; privacy; and the culture of care;and a perceived difference between thevalues of nurses and those of doctorsand patients families.

Medical nurses expressed the need formore support in these areas

Organizational: Biomedicalculture of care; time andprivacy; communication andcollaboration with MD

Thompsonet al (2006a)Canada

Purpose: To examine the nursingbehaviors and social processesinherent in the provision ofquality EOL care.

Study design: QUAL groundedtheory

Sample: Generalist femaleRNs: N 10Age: [18-65] years

YOP 11.5 yearsFaith: N/ASetting: two university-affiliated hospitals; fouradult inpatient medicalunits

Overarching theme: Creating a safepassage for heaven with the followingsub-processes: facilitating an maintainlane change; Getting whats needed;Being there.Main barriers identified by nurses: (1)medical factor was a significant barrierresulting in delayed transition fromcurative to palliative; complicated byepisodic and fluctuating nature ofchronic illness; (2) patient and familyfactors: changing lane s affected bypatients age, lack of patient and familyknowledge about palliative care andwith resultant unrealistic treatmentexpectations, and misunderstandingabout illness; (3) organizational factor:lack of privacy; Increase frustrationand absence of palliative carephilosophy or dependant on the greatvariability of physician present on unit;(4) professional factor: divergentprofessional paradigms espoused bynurses and doctors: nurses critiquingthe medical model predominance overnursings holistic model of care.Facilitators: (1) Patient and familieshaving a clear understanding of thenature and prognosis of the illness;when end-of-life discussions occurwhile the patient is still capable ofparticipating in decision making; and(2) nurses level of experience.

Organizational: Biomedicalculture of care; time andprivacy; communication andcollaboration with MD

Continued

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Table 1. Continued


Thompsonet al.(2006b)Canada

Purpose: Reports on finding thatgenerated a conceptual model ofthe nursing behaviors and socialprocesses

Sample: N 10 Generalistfemale RNsAge: 1865 yearsYOP 11.5 yearsFaith: N/ASetting: two university-affiliated hospitals; fouradult inpatient medicalunits

To provide high-quality care on acutemedical unit is a complex processinvolving many factors related to thepatient, family, healthcare providersand the context in which provision ofend-of-life care takes place.

Nurses are striving to provide high-quality EOL care on acute medical unitwhile being pulled on all directions.

Hopkinsonet al. (2005)UnitedKingdom

Purpose: Report ofphenomenological study fromHopkinson et al (2003)Study Design: Qualitativephenomenology.Method: One-on-one interview

Sample:28 RNsAge: N/AFemale: N 27YOP:[,2 months. 3 years]Faith: N/ASetting: 8 acute medicalwards

Relationships: give and receiving care;approach that is inconsistent withpatient centered care.Nurses used a structured approach toovercome some of the difficulties fromnot knowing what to say.

Nurses were controlling involvementotherwise they would experiencedistress, which would detract themfrom the care of other patients. Nursesneed to establish a balance betweenemotional involvement care vs.emotional distance.

Learning from experience: experientialknowledge is what really helped nursesto care for dying people; nurses studieswere of little importance. Nursespersonal comfort with EOL care &personal history influenced theexperience, which also help withnurses revision of ideal way to die.

Nurse factors: Personal idealof care; clinical experience &personal experience

Borbasi et al.(2005)Australia

Purpose: Explore nursesperceptions of the care providedto ESHF patients in communityand hospital settings

Study design: In-depth, open-endedinterviews

Sample: N 12 RNsAge: N/AYOP: N/AFaith: N/ASetting: Three acute care sites& five community nursing

Nurses reported that good deathrequires open communication withinterdisciplinary members & palliativecare involvement.Bad death was often the result of aconspiracy of denial; lack of consultationwith palliative care team; fear ofdiscussing death; failing to managesymptoms lack of resources., impositionof healthcare professionals values. Lackof communication was more present inmedical units and had a profound effecton nurses; nurses identified a greaterprocess of medicalization of deathleading to bad death.

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Table 1. Continued


Hopkinsonet al.(2003)UnitedKingdom

Purpose: Develop an understandingof care for dying people inhospital from the perspective ofnewly qualified nurses

Study design:Qualitative phenomenologystudyCross-sectional interview-basedstudy

Method: Nondirective open style ofinterviewing

Sample: N 28 RNs28 RNs

Female: N 27YOP: ,2 months. 3 years

Faith: N/ASetting: 8 acute medical wards

Six essences of taking care of the dying:(1) personal ideal; view of how dyingpeople ought to be cared for; (2) theactual; part of your job; (3) theunknown; the humanly unknown andthe personally unknown; (4) the alone;others do not appreciate the personalmeaning of the experience; (5) thetension: is inevitable; one must learn todeal with tension, and nurses arefeeling inadequately prepared to do so;(6) the anti-tension: emotional distanceenables nurses to continue caring forEOL patients. Nurses expectation andpreparation are important for personalcomfort.

Organizational factors:Biomedical culture of care;collaboration andcommunication with MD

Nurse factors: Personal idealof care

Davidson et al.(2003)Australia

Purpose: To examine theperceptions of palliative careamong cardiorespiratory nurses

Study design:Qualitativecontent analysis

Method: Focus groups

Sample: N 35 RNsYOP: months to 25 years

Faith: N/ASetting:Coronary care, medicalcardiology, respiratory units

Four major theme identified: (1)searching for structure and meaning inthe dying experience of patents withchronic disease; (2) lack of treatmentplan and lack of planning andnegotiation; (3) discomfort dealing withdeath and dying; (4) lack of awarenessof palliative care philosophies andresources.New graduate understood palliativecare as pain management only.Nurses identified a lack of fit/integration between palliative carephilosophy and acute care.Facilitating factor: Collegial support:both formal and informal.

Organizational factors:Biomedical Culture of careCommunication andcollaboration with MD

Cramer et al.(2003)UnitedStates

Purpose: To describecharacteristics, attitudes andcommunications of nursesregarding hospice and caring forterminally ill patients.

Study design: Quantitative cross-sectional survey design

Sample:RNs: N 30Female: 94.8%Faith: Roman Catholic: 65.5%Deep faith: 67.2%YOP mean of 12.3 years

Setting:6 Connecticut Hospitals;Cardiology, medical,pulmonology, and oncologyunits

Nurses attitudinal characteristics suchas greater comfort with initiatinghospice discussion and greaterperceived added benefit of hospice weresignificantly associated with nursesincreased discussions of hospice.Internal medicine nurses had thelowest percent of nurses havingdiscussed hospice with terminally illpatients and families.Hospice training was insignificantwhen adjusted for religiousness,education, practice characteristics andpersonal experience.

Nurse factors: Individualcharacteristics andexperience as nurses

Continued

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Sasahara et al.(2003)Japan

Purpose: To investigate thedifficulties encountered bynurses who have cared forterminally ill cancer patients atgeneral hospital

Study design: Quantitative cross-sectional study.(response rate: 70.1%)

Sample: N 375 nursesRNs: 94%Female: 97%YOP: Mean 5.5 yearsFaith: N/ASetting:Three general hospitalsnear Tokyo;

Nurses experience a high degree ofdifficulty overall while caring for thedying, particularly withcommunication with patients andfamilies.Areas creating very much difficultieswere the following: communicationwith patients (62%) and their families(55%) and personal issues such asimmaturity with myself (56%).Unique features of this study youngnurses with little experience.

Communication andcollaboration with MDNurse factors: Clinicalexperience and personalexperience.

Oberle &Hughes(2001)Canada

Purpose: To identify and comparedoctors and nurses perceptionsof ethical problems in EOLdecisions.

Study design:Qualitative descriptive approach

Method: One-on-one structuredinterviews

Sample: N 21Female RNs: N 14MDs: N 7Female: N 1Male: N 6Faith: N/ASetting:Acute medical-surgicalunits

The defining features of uncertaintyaround end-of-life decision present inboth doctors and nurses.Differences between doctors andnurses ethical concerns were primarilyrelated to their perceived mandates ascaregivers. Key differences are thatdoctors are responsible for makingdecisions and that nurses must livewith these decisions. Yet, moraldistress was experienced in bothdisciplines

Scarce recourses: doctors concern aboutresources distribution and decisionsabout one patient impacting another.Nurses concern mainly due to inabilityto provide quality care because offinancial constraints and staffingcutbacks. Contextual featuresinfluenced ethical decisions such as:competing values between doctors andnurses and hierarchical processes.

Organizational factors:Biomedical culture of care;communication andcollaboration

Notes: N/A not available; YOP years of practice; MD medical doctor.

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studies (Pope et al., 2007, p. 109). Data extractedfrom original studies were summarized with respectto sample characteristics, settings, methods, and keyfactors reported as influencing nurses experience ofEOL care within acute medical-surgical units (seeTable 1).

RESULTS

Overall, the experience of acute care nurses provid-ing EOL care within a hospital environment waschallenging, but for some it was a time of personalsatisfaction and growth. Several factors were ident-ified as influencing the medical-surgical nurses ex-perience of caring for individuals at the end of life.These are detailed further below grouped as followed:1) factors related to organizational constraints, 2) fac-tors related to nursing and its professional ideal of agood death, 3) factors related to collegial collabor-ation and communication, and 4) factors related tonurses personal experience and personal resourcesfactors.

Organizational Factors

Culture of Care, Time and Privacy

The organizational factors were considered part oftheworking environment and not within nurses con-trol. Several studies addressed the difficulty associ-ated with nurses caring simultaneously for bothcurative and palliative patients (Hopkinson et al.,2003; Johansson & Lindahl, 2012; Smyth & Allen,2011; Thompson et al., 2006a; 2006b; Wallerstedt &Andershed, 2007). Nurses were aware of the needto establish meaningful relationships with dyingpatients, but, given the task-oriented culture ofmedical units, they felt they had to give priority tomeeting the physical needs of the acute patients(Clarke & Ross, 2006). As an example, nurses fre-quently reported that the spiritual needs of the dyingwere often given lesser attention than the morepressing and objective tasks to be accomplished foracute care patients (Roche-Fahy & Dowling, 2004).Furthermore, time taken to sit down and talk withpatients was hard to justify as actual work (Davidsonet al., 2003; Roche-Fahy & Dowling, 2004).

Even when time could be found, nurses identifiedimportant physical constraints from their workingenvironment, such as the lack of privacy and lack ofspace, further limiting possibilities for spiritual andemotional care (Clarke & Ross, 2006; Sasaharaet al., 2003; Smyth & Allen, 2011; Roche-Fahy &Dowling, 2004; Thompson et al., 2006a). However,nurses also recognized that a lack of time and practi-cal tasks were at times helpful strategies employed toavoid talking with dying patients (Clarke & Ross,

2006). The difficulty involved in the emotional workof the dying was also contrasted with the ease andthe comfort nurses felt toward providing physicalcare to active patients, which did not require asmuch emotional involvement (Roche-Fahy & Dowl-ing, 2004). Caring for patients receiving active treat-ments offered nurses the chance to gather thestrength and energy needed to care for dying patients(Johansson & Lindahl, 2012).

These cultural, physical, and time constraintswere not without consequences for nurses who ex-perienced tensions caused by their practice. Theyoften described feelings that had negative connota-tions: feeling physically and spiritually split be-tween work with terminally ill patients and thosesuffering acute illness (Johansson and Lindahl,2012, p. 2038); feeling helplessly torn between com-peting demands on their time (Hopkinson et al.,2003, p. 529); feeling inadequate from being unableto give dying patients and their loved ones whatthey needed (Johansson & Lindahl, 2012); and feel-ing hopelessness (Thompson et al., 2006a). Nursesoften perceived that the acute care environment didnot encourage sharing these feelings (Wallerstedt &Andershed, 2007) and that caring for dying peoplewas something that nurses had to accept as part ofthe job or something you get used to (Hopkinsonet al., 2003, p. 528).

Having to learn to deal with it on their own, nursesperceived a risk attached to identifying and develop-ing closeness with dying patients, mostly in terms ofa difficulty in letting go at the end of their shift andtaking work home with them (Wallerstedt & Ander-shed, 2007). To cope with the emotional demandsEOL care placed on them, nurses in several studiesspoke of the need to balance their engagement anddetachment (Hopkinson et al., 2005; Johansson &Lindahl, 2012; Roche-Fahy & Dowling, 2009). Thisbalancing act helped make it possible to care bothin the present and on a long-term basis (Hopkinsonet al., 2005).

Lack of Recognition of the Emotional Dimension ofEOL Care

As just described above, attending to the emotionalneeds of dying patients created dissonance withinacute care nurses who felt constrained to do sowithinan acute care environment that did not recognize theemotional dimensions of care. Yet, despite being de-manding work, when nurses were able to meet theemotional needs of dying patients, they describedthe caring experience as rewarding and gratifying(Johansson &Lindahl, 2012; Roche-Fahy&Dowling,2009). Nurses in several studies spoke of the worksatisfaction they derived from being able to care for


the whole person and also from their relationshipwith families (Johansson & Lindahl, 2012; Hopkin-son et al., 2005; Wallerstedt & Andershed, 2007).Johansson and Lindahl (2012) reported that nurseswere grateful for being able to share in the end of an-others life. Nurses viewed their caring practice as aprivilege and felt compelled to give back by involvingthemselves deeply in their work, in a totally compre-hensiveway (p. 2038). Nurses acknowledged the op-portunity that this deep involvement provided forself-knowledge, which was conceptualized as find-ing oneself, both as a person and as a professionalnurse (p. 2038).

Factors related to Professional Ideal of aGood Death

Nurses dedication to patient carewasmotivated by adesire to bring the life of the patient to a good end(Wallerstedt & Andershed, 2007; Borbasi et al.,2005; Thompson et al., 2006a; 2006b). Nurses whowere animated by this desire felt an inner rewardthat positively influenced their work (Wallerstedt &Andershed, 2007). A good death, for nurses, waspossible when patients and families: (a) were inclu-ded in decision making, (b) were kept informed, (c)accepted that death was imminent, and (d) were inan appropriate environment (Borbasi et al., 2005;Thompson et al., 2006a; 2006b). Nurses idealsaround a good death were described in terms ofachieving a peaceful and pain-free death (Borbasiet al., 2005; Davidson et al., 2003; Hopkinson et al.,2005). A good death also meant an opportunity fornurses to help prepare and be present with thepatients family members to say their goodbyes(Thompson et al., 2006a; 2006b; Hopkinson et al.,2003). However, some nurses also recognized thatdeath is not always a peaceful phenomenon (David-son et al., 2003), that problems at the end of life arenot always resolvable, and that suffering may verywell be inevitable (Oberle & Hughes, 2001; Hopkin-son et al., 2003). Nonetheless, despite this aware-ness, nurses experienced distress from not beingable to act on some preventable issues, such as ensur-ing proper symptom management (Davidson et al.,2003; Thompson et al., 2006a; Rice et al., 2008; Wal-lerstedt and Andershed, 2007).

Futile Care as a Source of Moral Distress

As discussed earlier, in several studies nurses descri-bed the biomedical approach to care (with its curativeinterventionist focus) as interfering with both theirability to provide high-quality care to the palliativecare patients and the process of transitioningpatients to palliative care (Davidson et al., 2003;Hopkinson et al., 2003; Rice et al., 2008; Thacker,

2008; Thompson et al., 2006a; 2006b). As a result,nurses spoke of the tension and moral distress theyexperienced when they provided futile care (treat-ment without benefit). Moral distress is defined asa painful psychological disequilibrium that resultsfrom recognizing ethically appropriate actions, yetnot taking them because of obstacles (i.e., lack oftime, supervisory reluctance, institutional policy, orlegal considerations) (Rice et al., 2008, p. 361). Fornurses, the moral distress was related to their per-ception of providing futile care (Thompson et al.,2006a; Davidson et al., 2003), which has been associ-ated with: (a) unnecessary treatment at the EOL, (b)initiation of extensive life-saving actions that onlyprolong death, (c) failure to ascertain family/patientwishes regarding these life-saving actions, and (d)communication deficiencies in discussing the impli-cations of life-saving treatments to assure proper un-derstanding on the part of patients and families (Riceet al., 2008; Thompson et al., 2006a; Wallerstedt &Andershed, 2007).

Communication and Collaboration withMedical Colleagues

Poor collaboration and communication with medicalcolleagues emerged as a strong factor influencingnurses perceptions of providing futile care (Clarke& Ross, 2006; Davidson et al., 2003; Rice et al.,2008; Sasahara et al., 2003; Thacker, 2008; Thomp-son et al., 2006a; 2006b). Lack of collaboration wascommonly discussed in terms of the personal attri-butes of physicians that impeded proper EOL care,such as lack of proper prognostication skills andlack of skills and knowledge of palliative care andsymptom management (Davidson et al., 2003; Riceet al., 2008; Thompson et al., 2006a; Wallerstedt &Andershed, 2007). Nurses dissatisfaction and frus-tration were also considered a direct consequence ofnursedoctor relationships that failed to supportand value nurses caring beliefs and behaviors(Thompson et al., 2006a; Clarke & Ross, 2006). How-ever, both nurses and doctors appeared to lack mu-tual appreciation of the moral burden carried byeach profession in the care practice of the terminallyill patients (Oberle & Hughes, 2001). Alternatively,nurses reported positive experiences in caring forpersons at the EOL when collaboration and com-munication among colleagues was present (Johans-son & Lindahl, 2012; Thompson et al., 2006a;Wallerstedt & Andershed, 2007). Collaborative ap-proaches to care were perceived to improve clarityin treatment plans, allowing nurses the time neededto prepare for patient death and further contributedto nurses positive experience (Thompson et al.,2006a; Clarke & Ross, 2006).

Medical-surgical nurses and end-of-life care 403

Communication and Collaboration with Patients/Families

Nurses also referred to patients/families letting goof curative treatments as another factor that furthercontributed to their perceptions of futile care (Bor-basi et al., 2005; Thompson et al., 2006a). Nursesidentified several barriers to patients transitioningfrom curative to palliative care, including: (a) lackof patient/family knowledge about palliative care,(b) unrealistic treatment expectations, and (c)misun-derstanding of the illness having progressed to aterminal state. Nurses believed that families denialof death brought false hope and did not facilitatea good death (Borbasi et al., 2005; Thompsonet al., 2006a). Nurses also perceived that bothpatients and families hopes were very much tied topatients continuing to receive active treatmentaimed at a cure (Borbasi et al., 2005; Thompsonet al., 2006a).

Individual Factors

End-of-Life Care Knowledge and the ClinicalExperience

Although the need for additional palliative educationwas identified in several studies (Davidson et al.,2003; Sasahara et al., 2003; Yin et al., 2007) mostlyin terms of developing necessary knowledge andproper symptom management, it was mostly nursesclinical experience that appeared to play a centralrole in influencing nurses comfort around the pro-vision of EOL care. To that effect, several studieshighlighted the invaluable knowledge gained fromyears of practice (Clarke & Ross, 2006; Crameret al., 2003; Hopkinson et al., 2005; Johansson & Lin-dahl, 2012; Roche-Fahy & Dowling, 2009; Smyth &Allen, 2011; Thacker, 2008). To that effect, a surveyconducted in three general hospitals situated nearTokyo revealed lack of professional experience as animportant factor linked to nurses experiencing ahigh degree of difficulty in terms of communicatingwith dying patients and families (Sasahara et al.,2003).

Nurses reported that their clinical experience pro-vided them with valuable and useful knowledgeabout spiritual care, which came mainly from yearsof practice and learning from patients and families(Smyth&Allen, 2011). Experience appeared particu-larly relevant while caring concurrently for bothcurative and palliative care patients (mixed load, asdescribed above), since it involved a necessary pro-cess of inner/psychological movement, whereby adeep knowledge of palliative care encounters andhaving good self-knowledge and knowledge ofothers were necessary (Johansson & Lindahl,

2012). Experienced nurses more readily identifiedother resources that could provide them with sup-port, such as communication skills, relationshipswith patients, personal beliefs and compassion, andfamily support (Hopkinson et al., 2005; Thacker,2008). Experienced nurses were practicing anti-tension activities, such as: developing mutuallysupportive relationships with other nurses or rela-tives, using assumptions that provided them reasonsfor decisions and actions, and controlling theiremotions so they could continue to care for both theirdying patients and other patients (Hopkinson et al.,2005).

End-of-Life Care Knowledge, Personal Experienceand Resources

Nurses professional experience was also influencedby personal resources such as religion (Bjarnason,2010; Cramer et al., 2003; Yin et al., 2007), althoughit is not exactly clear how religion might do so. Forexample, Bjarnason (2010) pointed out the literatureexploring the influence of healthcare providers reli-giosity on the care they deliver to patients at theend of life. The author defined religiosity as a setof beliefs regarding faith-based activities that areboth visible (e.g., church-going) as well as discreet(silent prayer) (p. 79). In another study, a positivecorrelation between nurses religiosity and level ofcomfort in educating patients about aspects of EOLcare was found. However, a negative correlationwas found between nurses religiosity and level ofcomfort with respect to withholding or withdrawingtreatment. Cramer and colleagues (2003), lookingspecifically at hospice discussions among nursesand terminally ill patients, found that greater reli-giousness was a factor that correlated with nursesbeing more likely to have discussed hospice withEOL patients/families. However, the authors poin-ted out other potential contributing variables sincethese nurses were also more likely to have discussedhospice when factors such as caring for a greaternumber of terminally ill patients, having a close fa-mily member or friend who had used hospice, andbeing satisfied with hospice caregivers were present(Cramer et al., 2003, p. 253). Thus, even though theseare correlating variables, they nonetheless highlightthe influence that nurses personal and professionalexperience can have on the EOL care they provide.

DISCUSSION

This is the first published review of research studiesfocusing on factors influencing the experience ofmedical-surgical nurses in acute care providingend-of-life care. As such, it contributes to our


understanding of this area. Our findings suggest thatcaring for dying individuals within acute care is com-plex, demanding, and challenging for nurses andthat multiple factors influence nurses experience.

The Value Placed on Emotional Labor

The organizational factors emerged strongly as fac-tors constraining nurses provision of good end-of-life care. The acute care environment was often de-scribed as unresponsive to nurses professional as-sessments in terms of the identified needs of thepatients/families, and to nurses needs in relationto the emotional work they provided to dying patientsand their loved ones. The lack of recognition of theemotional labor required in the care of dying patientsand their loved ones has been critiqued elsewhere(Sorensen & Iedema, 2009). Emotional labor is de-fined as a deep acting, where a personal exchangetakes place and the healthcare professional connectswith the patient to feel the emotion that they wish todisplay (Sorensen & Iedema, 2009, p. 7). It also in-volves managing feelings in both self and others(Maunder, 2006, p. 28) and is known to exert con-siderable demands on nurses (Davenport & Hall,2011; Stayt, 2009; Summer&Townsend-Rocchiccioli,2003).

In that respect, nurses frequently spoke of a need tobalance their emotional involvement to protect them-selves and to continue to care for other patients in thepresent and over the long term. In light of themultiplechallenges and constraints to EOL care identified inthis review, it is argued that emotional distancingmay very well be an inevitable coping strategy nursesuse to protect themselves form the suffering that re-sults from by being emotionally involved with EOLcare of patient/family may create (Davenport & Hall,2011). However, despite these organizational con-straints, nurses acknowledged gaining intense satis-faction from the relationships they were able tocreate with their patients.

Caring Ideal and Its Consequences

This satisfaction may be in part related to the pro-fessional ideals of nursing that are also influencingnurses understanding of caring and how they canbe fostered in their practice with dying patients andfamilies. Caring in nursing is a core value of the pro-fession aroundwhich nursing orients its occupationalideology (Maunder, 2006). In that respect, the caringexperience cannot be expressed as an impersonal gen-eralized stance of good will: it must be lived, commu-nicated intentionally, and in authentic presence(Boykin & Schoenhofer, 2001, p. 54). Positive experi-ences of caring for patients at the end of life were de-scribed here in terms of contributing to personal

growth, self-knowledge, and greater meaning in life.These findings echoed findings from a review thatlooked at factors that contributed to job satisfactionin nurses working in hospitals (Utriainen & Kyngas,2009), which showed that patient care was the majorfactor impacting on nurse job satisfaction.

Paradoxically, this ideal of caring has been cri-tiqued as potentially contributing to nurses generalsense of inadequacy and to the tensions they have ex-perienced in their practice (Ceci & McIntyre, 2001;Summer & Townsend-Rocchiccioli, 2003). To that ef-fect, Allen (2004) speaks of a mismatch betweenreal-life nursing work and the professions occu-pational orientation, mandating nurses to developemotionally intimate therapeutic relationships withthe patient. This is further supported by Summerand Townsend-Rocchiccioli (2003), who argued that,in acute clinical settings, with acutely ill patients re-quiring an extraordinary level of factual and skillknowledge, the ability to turn on the caring emotionmay be difficult if not impossible (p. 165).

Hope and Need to Go Beyond ItsMedicalization

This literature review clearly indicates that nursesexperience a great deal of distress from the perceivedfutility of the care they provide to dying individuals.This is not unique to generalist nurses and has beenabundantly acknowledged as a significant source ofstress for critical care nurses (Badger, 2005; Gelinaset al., 2012). It has been argued that the need to in-tervene until the very end of life may be a responseto the healthcare providers view that this is impor-tant to maintain a patients hope (Abu-Saad Huijeret al., 2009); however, this view has been critiquedas an incorrect conceptualization of terminally illpatients hope (Duggleby et al., 2010; Eliott & Olver,2002; MacLeod & Carter, 1999).

Several studies of the experience of terminally illpatients focused on peace and comfort at the end oflife and hope for the families, not on a cure (Dugglebyet al., 2010; Eliott & Olver, 2002; MacLeod & Carter,1999). In relation to nurses striving toward providingdying patients and their families with a good deathexperience, it can be argued that by using a holisticapproach to care nurses are implicitly addressingvery important dimensions of hope (Duggleby &Wright, 2005). However, nurses in this reviewmainlyreferred to hope in the context of curative intentionsand in terms of professionals and patients/familiesfalse hopes and death denial. The argumentdeveloped here is that this discourse emphasizesthe medicalization of hope; it is a discourse that is in-complete and insufficient (Eliott & Olver, 2002; Dug-gelby et al., 2010). As such, it may be necessary for


nurses to expand their discourse of hope for patientsat the end of life.

Nurses Attitudinal Characteristics andPersonal Resources

This review highlights the fact that, although formaleducation is necessary, it is insufficient to help nur-ses increase their level of satisfaction with the carethey provide. In that regard, a nurses personal atti-tudes toward death, personal experience as well asprofessional experience all play a significant role inincreasing the level of comfort and satisfaction withEOL care. As such, it may be important in any pallia-tive/EOL educational sessions to consider nursespersonal attitudes and beliefs in terms of the influ-ence these might have on nurses overall EOL careexperience. In fact, training interventions that con-sider the personal attitudes and beliefs of healthcareproviders may be more successful than those focusedonly on communication skills (Gysels et al., 2004).To that effect, Blomberg and Sahlberg-Blom (2007)concluded that for healthcare professionals to beclose and to share in the suffering of another humanbeing, aspects of personal identity such as self-knowledge, maturity, and security must be con-sidered in addition to experience and education(Blomberg & Sahlberg-Blom, 2007; Hopkinsonet al., 2003).

Collegial Collaboration and Communication

An important struggle faced by nurses was related tothe process of transitioning patients/families to pal-liative care. This is particularly difficult when a colla-borative relationship with physicians is lacking. Inthat regard, medical-surgical nurses are not the onlyones; the need to fight to ensure decent conditionsfor the death of patients has been identified by criticalcare nurses as the most distressing issue encounteredin EOL care (Gelinas et al., 2012). It is argued herethat thismay be due tomedical colleagues also experi-encing discomfort and difficultyaround timelyand ap-propriate EOL care and decision making.

In fact, a discomfort around end-of-life care inacute care physicians has been well documented(Badger, 2005; Sorensen & Iedema, 2009) alongwith the use of avoidance strategies to discuss sensi-tive issues, which are recognized in both doctors andnurses (Bloomer et al., 2011). There is a potent cul-tural fear of death and a tendency toward denial ofdeath that still prevail in Western societies (OGor-man, 1998), and healthcare professionals are not im-mune to these phenomena. Yet, these must beacknowledged if wewish to diminish the suffering ex-perienced by healthcare providers, patients, and fa-milies. As findings from this review suggest, when

healthcare professionals ignore their own discomfort,when they think it is not appropriate to displayemotions or share the emotions experienced,emotional detachment then develops. This emotionaldetachment, though at times healthy and necessary,can also result in failure to communicate effectivelywith patients, subsequently leaving healthcare pro-viders feeling helpless and dissatisfied with thecare they have provided (White & Coyne, 2011).

LIMITATIONS

This is a narrative review, and the analysis relies onthe interpretation of reviewers (Pope et al., 2007); assuch, the two authors crosschecked each others in-terpretations of the data from the studies reviewed.Although other interpretations are possible, thestrength of this review lies in the commonalitieshighlighted across studies, which may signal a needto pay closer attention to particular aspects of acutemedical-surgical nursing work. A few quantitativestudies were cross-sectional survey designs fromwhich correlations were not always easy to interpret.Finally, an additional limitation is a lack of an in-depth interpretation of cultural variation consider-ing that studies came from many parts of the globe;this was beyond the scope of our paper and not oneof this reviews objectives.

FUTURE RESEARCH

This review identifies important gaps in the re-search. First, there is a lack of intervention studiesspecifically aimed at identifying ways to best supportmedical-surgical nurses in their provision of EOLcare and which also consider the limits and particu-larities of themedical-surgical context of care. In par-ticular, intervention studies considering practicalways to recognize and support nurses emotionalwork in such a context are needed. Studies aimedat improving collaboration and communicationamong healthcare providers are also crucial in thatregard. Finally, there is an absence of critical studiesof nursing professional discourses, particularly withrespect to medical-surgical nurses practices of EOLcare. For example, it may be relevant to conduct fu-ture research exploring nurses discursive practicesaround the concept of hope or good death to helpreveal dominant ideologies and assumptions influen-cing nurses provision of end-of-life care.

CONCLUSION

This review has highlighted that despite the numer-ous challenges encountered within the hospitalenvironment, generalist nurses want to and are


dedicated to address the needs of patients at the endof life. This culture of care often hinders nurses ca-pacity to truly engage with patients and therebythreatens an important dimension of nurses practiceof EOL care: the patientnurse relationship. Thisrelationship is considered a necessary means fornurses to provide high-quality end-of-life care.Administrators and managers must acknowledgethe emotional impact that providing EOL care hason healthcare providers and provide resources to sup-port nurses and other colleagues emotional work.However, further research is required to developnecessary strategies for achieving meaningful out-comes in this regard.

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The provision of end-of-life care by medical-surgical nurses working in acute care: A literature reviewAbstractObjective:Method:Results:Significance of results:INTRODUCTIONMETHODSSearch CriteriaInclusion CriteriaLiterature Search

Analysis

RESULTSOrganizational FactorsCulture of Care, Time and PrivacyLack of Recognition of the Emotional Dimension of EOL Care

Factors related to Professional Ideal of a Good DeathFutile Care as a Source of Moral Distress

Communication and Collaboration with Medical ColleaguesCommunication and Collaboration with Patients/Families

Individual FactorsEnd-of-Life Care Knowledge and the Clinical ExperienceEnd-of-Life Care Knowledge, Personal Experience and Resources

DISCUSSIONThe Value Placed on Emotional LaborCaring Ideal and Its ConsequencesHope and Need to Go Beyond Its MedicalizationNurses Attitudinal Characteristics and Personal ResourcesCollegial Collaboration and Communication

LIMITATIONSFUTURE RESEARCHCONCLUSIONREFERENCES

palliative and supportive care

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