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End-of-Life Care

Introduction

The article by Ranse, Yates, and Coyer (2012) explores the perceptions and practices of Australian nurses caring for patients with terminal illnesses under critical care. The study aimed to examine the views and experiences of nurses providing end-of-life care to patients under intensive care1. The study involved RNs with varying levels of work experience providing end-of-life care in a hospital intensive care unit (ICU) in Australia. Using the convenience-sampling technique, the study recruited a sample of five nurses who participated in the study. The participants were female RNs (both young and experienced) working in the unit.

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Data collection involved the interviewing method, whereby respondents shared their views and experiences of critical care in the hospital. The semi-structured interviews allowed the interviewer to probe further the participants’ responses. Responses were recorded using an audio recorder, coded, and organized into major themes and sub-themes. On analysis, three major themes were apparent, namely, nurses’ beliefs regarding critical care, nursing interventions and practices, and end-of-life care in ICU settings. From these results, the authors conclude that hospital ICU settings allow critical care nurses to learn the best practices in end-of-life care, including patient care and family psychosocial support.

Findings

Rigorous research uses the appropriate instruments to achieve the aims of the study. About data collection, the study must employ tools that yield precise, full-range, and detailed data2. The semi-structured interviews used in the article involved open-ended questions relevant to the study’s objectives. This allowed the respondents to give qualitative responses relating to their end-of-life care experiences. In particular, each respondent gave her individual experience relating to treatment withdrawal for terminal patients. In this regard, the semi-structured interviews allowed a more precise measure of the nurses’ experiences and comparisons between the responses than standardized instruments. Comparisons between responses help reveal salient patterns and themes present in the data.

The interviewing method also allowed the interviewer to ask probing questions to obtain detailed data. Metadata is essential in discerning patterns present in the data collected. However, in this study, researcher observations during the interview session were not recorded. Observational data during an interview can help validate a respondent’s response during an interview. In hospital settings, including the ICU, observational data provide insights into nurses’ reports and routine practices. It also captures the social context of the practice environment2. Thus, observational methods can enhance the rigor of studies focusing on nurses’ end-of-life practices.

One of the key indicators of rigor in qualitative research is comprehensive data2. In this study, data were collected from only five nurses, which affected its rigor. Moreover, the rationale for the convenience sampling strategy is not explained in the article. The absence of multiple data sources also affected the rigor of the interviewing method. Additional data from observation of actual end-of-life care delivery could have enhanced the study’s rigor.

After data collection, qualitative tools are used to analyze the data and reveal major and minor themes. In the study, the responses recorded with a digital voice recorder were transcribed into verbatim reports before coding the qualitative data into themes and sub-themes. In qualitative studies, researchers achieve rigor through “iterative collection and analysis” of qualitative data2. In the study, data collection and analysis were not done concurrently.

The researchers first collected the data before organizing them into themes. To achieve rigor and data saturation in qualitative, analysis determines the amount of data to be collected. However, in this study, data saturation was achieved before analysis. The authors presented the study’s results to in-service nurses in the hospital who corroborated the findings1. In this regard, the study’s findings and conclusions are valid and reliable.

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Discussion

Certain nursing practices and behaviors promote quality end-of-life care of patients in ICU. The study found that nurses value end-of-life care, which requires advanced nursing skills1. The study also found that because caring for patients with terminal conditions is emotionally intense work, nurses need organizational support to deliver quality care. The authors also found that end-of-life care in an ICU context extends beyond caring for a patient to include family support. These findings largely corroborate the results obtained in similar studies.

A study by Beckstrand and Kirchhoff (2005), which examined critical care nurses’ behaviors and end-of-life care obstacles, identified family support methods, and behaviors that impede appropriate care decisions for dying patients. The effective family support behaviors identified include comforting family members following the death of their loved one and providing peaceful bedside care through regular and honest communication”3.

Ranse, Yates, and Coyer (2012) also identify giving comfort during bedside care and family support as important critical care nursing roles. The two studies differ concerning research methodology and scope. Beckstrand and Kirchhoff involved an experimental study design and included a sample of 1409 participants3. The study also examined the obstacles that critical care nurses experienced when caring for dying patients. In contrast, the article does not examine the challenges or obstacles that critical care nurses encounter when providing end-of-life care.

The article makes the finding that nurses value care given to critically ill patients in the intensive care unit or hospice settings. A similar study by Boyd, Merk, Rutledge, and Randall (2011) also establishes that nurses have “positive attitudes towards hospice care”, especially about medical prognosis4. The study involved a comparative survey of 31 nurses caring for oncology patients in a 500-bed capacity hospice facility4. However, unlike the article, the study found that patient and family opposition to a nursing plan of care is an obstacle to effective caring for oncology patients.

A phenomenological study by Johnson and Gray (2013) that examined nurses’ views on care given to terminally ill patients in hospitals identified three main themes, namely, facing challenges, understanding critical care, and translating nursing theory into practice.

Critical care nurses experience emotional distress when caring for dying patients and thus, they need emotional support5. The article also cites emotional support for junior nurses as an important aspect of end-of-life care. Besides, Johnson and Gray (2013) explore the coping strategies nurses use to confront this challenge and how knowledge on end-of-life care can be applied in practice. The article reviewed does not cover these two areas.

The results of the article are comparable with findings from similar studies. Evidence from literature indicates that nurses place a high value on end-of-life care, which they consider as an area requiring specialized practice skills1, 4. Moreover, the theme of emotional support for nurses working in critical care settings is common in literature. Given the emotionally intensive nature of end-of-life care, the nurses need psychosocial support to cope with the challenges of the practice. Another theme present in the studies is family support, which is an essential nursing role. Nurses give bedside comfort and advice on available care options and prepare family members for grieving after the death of the patient.

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Some findings of the article differ from those of similar studies. The article did not explore the concept of comfort care in critical care settings and the obstacles nurses face. This can be attributed to the article’s use of small sample size (five RNs) and convenience sampling strategy, which could not allow data saturation. In addition, no further discussions were done to determine the respondents’ knowledge of comfort care, stress coping strategies, and supportive behaviors. In comparison, the other studies involved a large sample that allowed the collection of comprehensive data to support several themes.

Conclusion

The study gives important insights into the nursing role in ICU settings. Caring for dying patients is a challenging nursing role that requires organizational support. Nurses caring for patients at the end-of-life stage experience emotional distress that may hamper patient care and family support. Thus, healthcare organizations should make counseling services accessible to critical care nurses to help them cope with the intensity of the practice.

Nurses play a critical role in promoting positive experiences for both the patient receiving intensive care and family members. They provide comfort during bedside care and support the family when the patient dies. In this regard, open and regular communication with the patient and family is important to reduce anxiety and distress associated with end-of-life care. Educating nurses about end-of-life care will help them offer quality bedside care to the dying patient and support the family throughout this period.

References

  1. Ranse K, Yates P, Coyer, F. End-of-life care in the intensive care setting: A descriptive exploratory qualitative study of nurses’ beliefs and practices. Aust Crit Care. 2012;25(1):4-12.
  2. Coker E, Ploeg J, Kaasalainen S, Fisher A. Assessment of Rigour in Published Nursing Intervention Studies that Use Observational Methods. The Qualitative Report. 2013;18(67):1-23.
  3. Beckstrand RL, Kirchhoff KT. Providing End-of-life Care to Patients: Critical Care Nurses’ Perceived Obstacles and Supportive Behaviors. American Journal of Critical Care. 2005;14(1):395-403.
  4. Boyd D, Merk K, Rutledge DN, Randall V. Nurses’ perceptions and experiences with end-of-life communication and care. Oncol Nurs Forum. 2011;38(3):229-239.
  5. Johnson SC, Gray DP. Understanding Nurses’ Experiences of Providing End-of-Life Care in the US Hospital Setting. Holistic Nursing Practice. 2013;27(6):318-328.

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