This article has been retracted and is available online only: Exploration of Iranian intensive care...

RESEARCH

doi: 10.1111/j.1478-5153.2012.00505.x

Exploration of Iranian intensive carenurses’ experience of end-of-lifecare: a qualitative studySina Valiee, Reza Negarandeh and Nahid Dehghan Nayeri

ABSTRACTBackground: A challenge for intensive care nurses is providing the best possible care to patients in an end-of-life stage. The fact that thelives of some of their patients end, despite caretaking, can affect the psychological state of the nurses and, finally, providing care to the patients.Lack of attention to such an issue can bring about unpleasant consequences for both patients and nurses.Aim: The present research was carried out with the aim of exploring the experience of providing care for end-of-life patients among nursesworking at intensive care units.Methods: This research is a qualitative, content analysis study. The data was collected by using purposive sampling through in-depthinterviews. The interviews were conducted with 10 nurses working at intensive care units. Then the data was saturated and finally analysedthrough the conventional content analysis.Findings: Three themes emerged out of analysing the collected data about the experience of providing care to the end-of-life patients. Thefindings showed that providing care to such patients was accompanied by psychological harm, lack of feeling indebted by the nurses towardspatients and sticking to the inner voice for the nurses.Conclusion: The results of the study have increased the current knowledge over the experience of providing care to end-of-life patientsat intensive care units. It also has revealed the need for providing the nurses with psychological support, accommodating the possibility foroffering complete care, attending to and managing the conditions of the patient and their families and engaging nurses in decision-makingabout end-of-life patients.Relevance to clinical practice: Managers ought to provide specialized units for providing care to end-of-life patients by attending tothese dimensions and supporting the nurses at the same time.

Key words: Content analysis • End-of-life care • Nurse • Qualitative study

BACKGROUNDDeath is an unavoidable phenomenon for all creatures(Haisfield-Wolfe, 1996). Nowadays, with regard to theincrease in lifespan and advancement of technology,many people are in need of end-of-life care and offeringcare to the end-of-life patients is one of the mostimportant concerns in health systems (Beckstrand andKirchhoff 2005). The occurrence of death is common inintensive care units and it is, by no means, a simple and

Authors: S Valiee, MSN, PhD Candidate, School of Nursing andMidwifery, Tehran University of Medical Sciences, Tehran, Iran; School ofNursing and Midwifery, Kurdistan University of Medical Sciences,Kurdistan, Iran; R Negarandeh, Associate Professor, Nursing and MidwiferyCare Research Center, School of Nursing and Midwifery, Tehran Universityof Medical Sciences, Tehran, Iran; N Dehghan Nayeri, MSN, PhD, AssociateProfessor, Nursing and Midwifery Care Research Center, School of Nursingand Midwifery, Tehran University of Medical Sciences, Tehran, IranAddress for correspondence: N Dehghan Nayeri, School of Nursingand Midwifery, Tehran University of Medical Sciences, Tehran, IranE-mail: [email protected]

natural issue (Chapple, 1999). As a matter of fact, thedeath process at intensive care units can be complex,noisy and complicated (Beckstrand and Kirchhoff 2005)and most of the patients are hospitalized in these unitsbefore their death and are in need of care. Lorenz et al.(2005) consider end-of-life as a fleeting part of humanlife through which the patients and their familiesstruggle for survival. This situation is brought about bydifferent conditions, including cardiac disease, cancer,stroke and varying acute and chronic diseases. Rosset al. (2000) consider the end-of-life care as a kind ofcare in threatening conditions by which individualslive and because of which, they die. Therefore, suchcare is given for patients with a range of varyingconditions through days or even weeks before death(O’Shea et al., 2008).

Nurses, as members of the care providing team, playa crucial role in providing care to end-of-life patientsand their families (Dunn et al., 2005). Meanwhile,

© 2012 The Authors. Nursing in Critical Care © 2012 British Association of Critical Care Nurses 1

End-of-life care experience

providing care to such patients and their families isoften stressful and tough for nurses who are in constanttouch with them (Baggs and Schmitt 1995). Statisticsshow that one out of five end-of-life patients hospi-talized at intensive care units die (Angus et al., 2004).Hence, the nurses who are selected for working inthese units might face problems. For instance, througha study in Iran, Aqhajani et al. (2010) showed that thenurses who work at the intensive care units bear moredeath anxiety compared with nurses at other units.One of the most important reasons for this situationis that nurses are in constant touch with end-of-lifepatients in contrast with all other members of thecaring team who do not stay beside patients after vis-iting them (Maeve, 1998). As a result, nurses have animportant role in promoting end-of-life care throughdifferent contributions at bedside, research, education,management and policy making (Briggs and Colvin2002).

On the other hand, the kind of care that nurses pro-vide for the end-of-life and dying patients is influencedby their perception and attitude towards death (Dunnet al., 2005). For instance, in Calvin et al.’s (2007) study,the perception of nurses at Neuroscience intensive careunits about end-of-life care has been reported to be inthe form of confusion, hopelessness and prostration.In another study, carried out by Oberle and Hughes(2001), witnessing the suffering of patients and lackof certainty about the best measure for the patientsand their families had been mentioned as moral issuesat end-of-life stage. Besides, in Calvin et al.’s (2009)study, which examined the experience of nurses atcardiovascular intensive care units regarding end-of-life care, excessive exhaustion in treating the patientsand moving on a straight line was reported. Gener-ally, it must be mentioned that nurses’ experiencesin end-of-life care can be effective in their manner ofcaretaking (Beckstrand and Kirchhoff 2005). Despitethe available researches on the sufferings and defectsinvolved in offering care to end-of-life patients, stud-ies on the nurses’ experience with regard to thesepatients, especially at general intensive care units arelimited (Dunn et al., 2005). Hence, with regard to lackof conducted studies about this issue in Iran and theeffect of experience in providing care to end-of-lifepatients on the quality of caretaking for patients andalso for the psychological well-being of nurses, thesignificance of embarking on this study is indicated.Because the nurses’ understanding is affected by theircaretaking experiences, one way of explaining this areais the exploration of nurses’ experiences. Explorationis the first step among different steps in promotingcare quality and detecting the experience of caringfor end-of-life patients, and it would be useful in

suggesting strategies at both personal and professionallevels.

Research aimThe present research was carried out in order to explorethe experience of caring for end-of-life patients by theIranian nurses working at intensive care units.

MATERIALS AND METHODSDesignWith regard to the aim of this research, which was theexploration of care-related experience for end-of-lifepatients by the Iranian nurses working at intensive careunits, qualitative content analysis method was usedwhich offers instruments for examining experiencesand results in the acquisition of valuable and in-depthdata out of samples (Lichtman, 2010). The presentresearch is a qualitative, content analysis study. Con-tent analysis enjoys a valuable status among researchesand it is an appropriate tool for qualitative research(Krippendroff, 2004). In this research, the conven-tional content analysis method was used in which theresearcher refrains from using predefined categoriesand instead allows the categories and their names tobe taken from the data. Therefore, the researcher iscompletely saturated in the data to arrive at a newunderstanding and insight. Initially, the data analysiscommenced with frequent reading of the text for get-ting immersed in them and finding a general feeling.Then, the texts are read word-by-word in order toextract the codes. This process is continuous and con-sistent from the extraction of codes to naming them.After units, the codes are categorized into strata on thebasis of their similarities and differences and finally aset of examples are prepared for each of the themesfrom the data. Among the advantages of this approachis that the results are directly arrived at by the datataken from the participants in the research withoutimposing one’s idea (Hsieh and Shannon 2005; Elo andKyngns 2008).

ParticipantsIn order to do this study, purposive sampling was usedso that the nurses working at the general intensive careunits, who had at least a 1-year record of experienceat intensive units and had taken care of the end-of-lifepatients, were selected.

Data collectionAfter presenting the informed letter, data was gatheredthrough in-depth interviews using the following steps:explaining the research objective and the manner

2 © 2012 The Authors. Nursing in Critical Care © 2012 British Association of Critical Care Nurses


of conducting it, providing assurance about theconfidentiality of the information, briefing them abouttheir right to withdraw from the study and gettingthe informed consent form. The interviews wereconducted with 10 nurses in Persian and continuedtill it reached the required richness, which finallyresulted in the saturation of data for the researchers.The interview session started with posing one generalquestion about the experience of providing care andthen, its in-depth examination began based on them.Some of the questions which had been considered asan interview guide were What experience did youhave when taking care of these patients? What wasthe difference between taking care of these patientsand other patients? Accordingly, the participants wereasked to present other points also which came totheir minds and had not been addressed during theinterview. The interview was held within a 45 to 60-min period, recorded on tape, immediately transcribedon paper and then analysed.

Ethical considerationsThis study was approved by the research committeeof the Tehran University of Medical Sciences (TUMS).All participants were volunteers and the consent formwas obtained from all of them in which the volun-tary nature of their participation had been mentioned.The participants were assured that they could with-draw themselves from the study at any time and theirnames alongside other significant details that mightreveal their identity would not be published in thestudy report. All the participants’ names were changedinto codes during the transcription of the interviews,data was locked in a separate location and the codedsets of information were used for data analysis anddiscussions. The quotations mentioned in the Find-ing section were coded by participants’ code numberthat was listed at the end of each quotation betweenbrackets.

RigorRigor or trustworthiness in qualitative research meansmethodological soundness and adequacy. Researchersmake judgments of trustworthiness possible throughdeveloping dependability, credibility, transferabilityand confirmability (Holloway and Wheeler 2010).There are a number of ways in which the qualitativeresearcher can check and demonstrate to the readerwhether the research is trustworthy or not – memberchecking, peer debriefing, triangulation, audit trial,thick description and reflexivity (Streubert-Spezialeand Carpenter 2003; Holloway and Wheeler 2010).The researchers composed of two associate professors

Table 1 Summary of themes and subthemes

Themes Subthemes

Psychological harm Psychological pressure in providing carePainful nature of the patient’s family’s reactionEffect of patients’ conditions on the caring

experienceLack of feeling indebted

by the nurses towardspatients

HereafterBeing advocate towards the patientSupporting ethics, conscience and value

Sticking to the inner voice Lack of hope for the resuscitation of the patientBeing forced to follow the doctor’s orders

who helped to conduct and supervise several quali-tative studies and a PhD Candidate of Nursing whohad teaching and clinical experiences in Critical CareNursing. They have published numerous articles ininternational journals with a qualitative approach. Thelatter (S. V.) conducted interviews and analysed datawith collaboration of his professors (N. D. N. andR. N.). In order to increase the rigor of the presentstudy, the following points were taken into account:allocation of a proper place and adequate time for col-lecting the data, having a suitable relationship withthe participants, using the complementary views ofthe colleagues, going over the handwritten materi-als for the participants and examining the data by allresearchers for increasing the acceptability of the codeddata.

FindingsThe participants included nine working nurses anda head nurse. They consisted of nine females and onemale nurse. The average age of the participating nurseswas 33·5 years. The participants in this research had atleast 1 year and at most 18 years of experience, with anaverage rate of 4·5 years in an ICU ward. Among theparticipants, nine of them held a Bachelor of Science inNursing and one had a Master’s Degree. Data analysisyielded eight subthemes and finally three main themesabout the experience of caring that had been acquiredwhich consisted of: psychological harm, lack of feelingindebted by the nurses towards patients and stickingto the inner voice for the nurses (Table 1).

Psychological harm

The majority of the participants pointed out tothe psychological harm resulting from contact andproviding care to end-of-life patients when mentioningtheir experiences which finally gave rise to a theme,titled ‘the psychological harm,’ which consistedof three subcategories, namely, ‘the psychologicalpressure in providing care,’ ‘the painful nature of the



patient’s family’s reaction’ and ‘the effect of patients’conditions on the caring experience.’

The psychological pressure in providing care. Theparticipating nurses considered the experience ofproviding care to end-of-life patients as a tough oneand stated that taking care of these patients has hada negative effect on their spirits and brought aboutfeelings of hopelessness, sympathy and compassiontowards the patient’s conditions, and also feelings ofdepression and anxiety in them. For instance, one ofthe participants in this study expresses this issue as

‘With regard to this point that the majority of patientswho had been hospitalized in our ward did not haveany hope of returning to life, the kind of psychologicalharm to us would be far more.’ (Code 7)

Another participant states this harm as

‘Working for and nursing those patients who are atthe end-of-life phase is way too hard and painful. . . .Witnessing their death is a very difficult experienceand it can result in the weakening of the nurses’morale for a long time.’ (Code 7)

This sense of psychological discomfort is in mostcases a consequence of the patients’ conditions andworking in such conditions had resulted in havingpsychological torture for some nurses.

‘These patients have too difficult conditions and caringfor them is like torture for me. I feel that God ispunishing me; I feel that a good guy never gets stuck insuch conditions to observe difficult things.’ (Code 2)

The painful nature of the patient’s family’s reaction.Another important dimension of psychological harm,when providing care to end-of-life patients amongnurses, is the painful nature of the reaction from theside of these patients’ families. This reaction per sehad resulted in psychological harms like psychologicaldiscomfort, sense of commiseration, attempt towardscontrolling one’s feelings, difficulty in making contactwith families of these patients, etc. In this regards, oneof the participants stated that

‘Facing with families of these patients causesdiscomfort in nurses when they see their familiescoming and seeing their beloved in that patheticcondition and I, as a nurse, cannot be a good supportresource for them, because once you try to keep yourcool and explain the condition of the patient gradually

and calmly, you have to admit that their patient’scondition would not change till his/her heart stopsbeating.’ (Code 4)

Another participant pointed to the negative effect ofthe patient’s family’s reaction.

‘One of the personal problems once taking care ofend-of-life patients is the painful feeling that is causedfor me by virtue of the effect of the patient’s conditionon their families, for example, I saw their discomfortand I myself did not have a good feeling. . . . I am onlyobliged to commiserate with their families.’(Code 8)

This effect is the result of the toughness sometimesinvolved in communicating with these patients’families especially at the time of refusing to admitthe condition of end-of-life patient.

‘One of the problems that we face with, whentaking care of the end-of-life patients especially thosesuffering from brain death, is their families; the morewe try to tell them that their patient’s conditionremains stable and won’t change, the more they woulddeny and show different psychological reactions thatare painful for us too.’ (Code 4)

The effect of patients’ conditions on the caringexperience. One of the other subthemes which wasvery important in participants’ views was the influenceof the end-of-life patients’ conditions on the caringexperience of nurses which depended on differentfactors, including age, level of alertness, ability to makecontact, possibility for organ donation, the situation ofthe survivors, duration of care and the need of allpatients to get care.

‘If our patients are young, its stress is more but if theyare old and have remained a long time on bed, we feelmore comfortable when announcing the end of CPR.’(Code 1)

Another participant points out to the issue ofpatient’s age as

‘Taking care of those patients who are at the end-of-lifephase is way too difficult and painful, especially whenthe patient is young.’ (Code 7)

‘The kind of feeling that I personally get when takingcare of such patients is really difficult and one becomesimpressed, especially when the patient is young;taking care of them becomes really tough for me.’(Code 4)



Besides patient’s age, among the other importantfactors in providing care to end-of-life patientsfrom the point of view of the participants is thecondition of alertness among this group of patientswhich was pointed out to a lot by most of theparticipants.

‘If the patient is conscious, the end-of-life caretakingbecomes more difficult; it is very difficult to tell thetruth to them.’ (Code 4)

Also, having or lacking reaction from the side of thepatient towards the caretaking procedure was amongthe influential factors on the nurses’ experience inproviding care.

‘Because most of these patients are not able to expresstheir feelings, reactions and symptoms, working withthem is way much tougher compared with workingwith the alert patient who has been witness to theprogression of therapies and can express his/herfeelings.’ (Code 7)

With regard to this point, that some end-of-lifepatients belong to the brain death group of patients,organ donation is among the most important factorsthat is influential on the nurses’ experience.

‘Brain death patients are the reservoir of our ward,since they are able to save the lives of several people. . .taking care of such patients, irrespective of the routineworks that we do for them, can give us hope.’ (Code 4)

Furthermore, ‘the length of caretaking’ or theduration of staying at ward for patients is among theother important factors. One of the participants statesin this regard that

‘When these patients stay longer at ward, it can resultin the weakening of the nurses’ spirits.’ (Code 7)

The need of all other patients was among the mostimportant factors that could affect providing care toend-of-life patients which was pointed out to by one ofthe participants as

‘It doesn’t make difference for me that how much thealertness level of the patient is – 3 or 15 – I provideservices to them. However, in critical conditions, thepatient who is alert and has more hope for survivingand is not in a good condition now has priority.’(Code 2)

Another participant pointed out to this problem as

‘If one claim that there is no difference between end-of-life patients and other patients, it would be a lie. . . wespend more energy for the patient who is more alertand has more hope for recuperation and survival.’(Code 3)

Lack of feeling indebted by the nurses towardspatients

Among the other important themes, which waspointed out by participants when expressing theirown experience was the nurses attempt for lack offeeling indebted towards patients, resulting from theremembrance of the Hereafter, being advocate towardsthe patient and supporting ethics, conscience and valueas the subcategories.

Hereafter. Accordingly, most of the participants inthe research pointed to this issue, among other things,that taking care of the end-of-life patients associatesthe Hereafter and the life after death for them andconsidered this issue as effective on their presentationof complete care for these patients. A nurse, with4 years of experience at the ICU, pointed out to thisissue as

‘When taking care of these patients, I usuallyremember the Hereafter and the Day of Judgmentfor 10 to 15 minutes. . . . I think for a few minutes if Ihave done all the nursing works for them and whetherI am indebted towards them or not.’ (Code 1)

This remembrance and the attempt for not feelingindebted towards the patients are as follows for anothernurse:

‘I always feel God by my side when I am working forsuch patients, as if He’s looking at me; I always havethis feeling that if I work less for my patient, I mightget in the same problem and somebody else would dothe same lack of service for me.’ (Code 2)

Furthermore, the situation of the end-of-life patientsand the attempt for providing complete care to themwere the results of generalizing the patients’ conditionto oneself and family among the nurses. For instance,one of the nurses pointed out that

‘In most cases, we generalize the patients’ problems toourselves and our families. . . for example, whenever Itravel by car, I feel as if this is the last time and thinkthat an incident might happen for me and maybe I



become a patient at ICU one day myself. . . For this,I try to give the best imaginable sort of care at mydisposal to them.’ (Code 4)

Being advocate towards the patient. Another impor-tant subcategory for the attempt of nurses not feelingindebted towards the patients is the feeling of beingadvocate towards the patient.

‘These patients are more sensitive. . . for they cannotdefend their rights. The only things that remain are I,the patients and God.’ (Code 2)

This feeling had led to providing more attention tothese patients by nurses.

‘The end-of-life patients need more to caring, forthey are completely dependent and do not have anykind of independence or will power and the nurse isresponsible for taking care of them.’ (Code 8)

Supporting ethics, conscience and value. In additionto the sense of being supportive, the attempt forproviding complete care from the side of nursesemanates from ethical, value-and-conscience-relatedissues.

‘From the point of conscience, one can not satisfyoneself to do less for them or to ignore them since theyhave a limited time for life and survival in this worldand this makes it necessary to give them a completecare.’ (Code 4)

Sticking to the inner voice

Another acquired theme form the viewpoint of theparticipants was sticking to the inner voice as nursespointed in their sayings that despite lack of hope for theresuscitation of the patient and being forced to followthe doctor’s orders in many respects of providing ornot providing care to these patients, they had listenedto their inner voice and hence presented the necessarycare for the end-of-life patient.

Lack of hope for the resuscitation of the patient.

‘When I see everything that I do for my patientis useless, and it doesn’t have any result and mypatient’s situation becomes worse and worse day byday, I feel pressured. . . . Meanwhile, you cannot doanything for them and you don’t become satisfied withdoing nothing for them.’ (Code 6)

Being forced to follow the doctor’s orders. Nonethe-less, the participants in the research tend to point outthat despite having no choice and the urgency for fol-lowing the doctor’s orders; they had given care on thebasis of their internal principles.

‘Unfortunately, we do not have any choice whentaking care of these patients and we ought to followdoctor’s orders and if the patient does not haveany prescription for medication, we cannot prescribemedicine while the patient is in need of it and I tryto do whatever I can for the patient in these cases.’(Code 2)

The participants in this research pointed outthat despite being under obligation, they tried todo whatever they could for the end-of-life patientaccording to their own view, experience, record andinternal motivation.

‘I have frequently administered the resuscitationdespite the absence of any direction for doing it andI thought by myself that it was the best thing to doand I tend to do whatever I see as true from within.’(Code 4)

Generally, it must be admitted that the experienceof nurses at the intensive care units about takingcare of the end-of-life patients was materialized inform of psychological harm, attempt for not feelingindebted towards the patient and sticking to innervoice.

DISCUSSIONThe findings of the present study increase our under-standing about the experience of nurses who work forthe end-of-life patients at general intensive care unitsand give us suitable information about the uniqueexperience of this group of nurses. The unique aspectof the present research is that the participating nurses inthis research discussed about their experiences at gen-eral intensive care units with the end-of-life patients inthe field of Nursing in our country.

According to the research findings, the participatingnurses had suffered from psychological harm due toproviding care to the end-of-life patients and this issuewas in line with Calvin et al.’s (2007) study in whichthe nurses working at the Neuroscience intensivecare units expressed their experience of working forend-of-life care as including of communicative andemotional processes, like being confused, hopeless anddisappointed.



Also, in Obreleh and Huges’ (2001) study, such apsychological side effect of caring was expressed bynurses as ‘witnessing the suffering of the patient.’Another important point in the present research isthat besides the imposition of psychological pressure,emanating from providing direct service to end-of-lifepatient, witnessing the reaction of family membersof these patients had been painful for nurses andwould increase their psychological harm. The issue offamily has been reported as attending to the presenceof family in taking care of the end-of-life patient inCalvin et al.’s (2009) study. So, it seems that withregard to the imposed psychological harm to nurses,supportive systems for them have been provided by themanagerial system and it is hoped that by consideringthe special strategies in declaring the condition of thepatients to their families by nurses and taking trainingcourses about how to release bad news, and supportingthe patients’ families beside the manner of paying visitto the end-of-life patients, this psychological harmwould be reduced among nurses. Meanwhile, manystudies have pointed out the issue of psychologicalsupport for the nurses who work at the intensive careunits (Dunn et al., 2005; Iranmanesh et al., 2010).

The nurses participating in the present study pointedout the effect of different factors, including patient’sage, alertness situation, the likelihood for commu-nicating and donating organ on their experience ofproviding care to end-of-life patients. This could haveresulted from the research setting which consists ofthe general intensive care units, as nurses had beenconfronted with a wide variety of end-of-life patientswhich could be due to an array of different diseasesbased on the available literature (O’Shea et al., 2008). Allin all, it seems that providing end-of-life care to end-of-life patients has been tougher for this group of nurseswho have dealt with young and alert patients whoare unable to communicate and those who have had along-lasting stay at ward, and who have come acrosswith the toughness of the family’s conditions after thedeath of the patient(s), aggravated by lack of possibilityfor donating organ. Among the very important condi-tions from the viewpoint of the participating nurses,which have been pointed out in this research, is prior-itizing other patients, especially in critical conditions.This issue highlights the necessity for the end-of-lifecaretaking nurses to undertake the providing of care tofewer number of patients and if possible, specializedunits for caretaking of the end-of-life be accommodatedfor them and also the nurses opt for providing careperiodically and on a cyclical basis at different units.

In addition, nurses participating in this researchpointed out to ‘feeling not indebted by nurses towardspatients’ and the mentioning of this experience from

the side of the participants could have been totallyoriginated from the sociocultural and specially thereligious context, as individuals’ religious tendenciesaffect on their attitude towards life, death and makingdecisions about end-of-life caretaking (Zahedi et al.,2007). The majority of Iranian people and health careproviders are Muslim, believing in one God, Allah,the life after death (hereafter) and resurrection ofthe body. Judgment by God in hereafter accordingto a person’s deeds leads him/her to heaven or hell(Carey and Cosgrove 2006). For Muslims, life is sacredbecause God is its origin and its destiny. Life is a divinetrust and an opportunity for spiritual refinement anddeath does not happen except by God’s permission;however, Islam recognizes that death is an inevitablepart of human existence (Hedayat and Pizadeh 2001;Schedina, 2005).

The saving and caring of a life is also consideredone of the highest merits and imperatives in Islam.Therefore, health care providers must do everythingpossible to prevent premature death and the primaryobligation of a Muslim health care provider and doctoris to provide care and alleviate pain (Zahedi et al., 2007).

Lack of being indebted is a feeling through whichthe nurses wondered if they had done their best or ifsomething had been missing through their providingof care to patients after the caretaking process hadbeen completed. Nonetheless, it must be pointed outthat this feeling might also emerge in daily life andwhen taking care of ordinary patients in all otherunits. However, with regard to the closeness of end-of-life patients to death and their disability in takingcare of themselves and defending their own rights,providing special caring units for this group of nurseshas received more attention. Nevertheless, this feelingin individuals can result in providing complete careto patient according to an internal emotion for beingresponsive to God in the Hereafter and not feelingindebted towards patients on one hand and it can alsobring about a sense of guilt and indebtedness in casenurses think that they have not done their best for theirpatients or if their patients pass away. In their study onIranian and Swedish nurses’ experience in providingcare to end-of-life patients facing death at oncologyunits, Iranmanesh et al. (2010) pointed out an ethicalneed for attending to the personal and professionalresponses of patients when taking care of the end-of-life patients. Also, it must be pointed out that thisfeeling is accompanied by reminding the Hereafter,feeling of being supportive to patients and value-driven and ethical issues, combined with the religiousviewpoint of the nurses. The nurses in this researchand similar researches, including Gaudine et al. (2011),had a sense of being coerced and obedient in their work



because of not having the power of choice and decision-making with regard to the condition of patient. Incontrast, the study of Latour et al. (2009) examinedthe involvement of European intensive care nurses’in end-of-life care decision-making and that 73·4%reported active involvement in the decision-makingprocess. The important point is that in most cases, theinstructed points have been opposed to their own ideaand opinion and their views have not been taken intoaccount in making decisions about providing care toend-of-life patients. Hence, nurses have administeredtheir own view, which indicates the need for furtherexamination to know why some nurses opt for doinga series of actions according to their own view whilehaving no hope for the survival of the patient.

Through this research, the researchers tried to usea set of measures for increasing the acceptability ofthe data and increase the scientific precision of theresults, including the allocation of proper place andsufficient time for collecting data, due communicationwith participants, using the supplementary viewsof colleagues, reviewing the hand writings for theparticipants and examining the data by all engagedresearchers. However, the generalizability of theresearch findings is limited because of the qualitativeapproach of the study and its administration at thegeneral intensive care units of one hospital. Hence,more studies ought to be conducted for furtherexploration of nurses’ experiences, especially aboutnursing in Islamic countries and all other religions andreligious groups in other countries.

The conducted exploration about the nurses’experience in providing care to end-of-life patientsprovided a valuable insight about the experience ofnurses at general intensive care units. In fact, thisexperience tends to be unique and belongs to specialconditions but the experience of this group attractedour attention to issues like the tendency of nurse for notfeeling indebted towards patients, the negative effect offamily members’ reaction on nurses, the effectivenessof patients’ condition, the necessity for attending toand prioritizing nurses’ work and the necessity forengaging them in decision-making about providingcare to end-of-life patients. Although the acquired

themes in this research had similarities with all otherstudies, some cases were also mentioned that weredue to the special field of the study. Despite the factthat nurses had been seeking to give end-of-life care,they have suffered psychological harm in doing sucha service which must be taken into account. Hence, itseems that further research must be carried out for abetter and more exploration of the themes, like nurses’views about psychologically supporting them, modelsfor cooperative decision-making, expressing beliefsabout death and demise, palliative cares for chronicallyill patients and the contribution of family in providingcare. Finally, the effect of supportive structures and theemotional support system for the nurses working atintensive care units must be examined.

CONCLUSIONNurses’ experience in providing care to end-of-life patients consisted of, ‘the psychological harmresulting from direct caring and observing the family’sreaction, the effectiveness of patients’ conditions,besides attempting not to feel indebted by nursestowards the patients resulted from being reminded ofthe Hereafter, being advocate towards the patient andattending to ethics, values and conscience, and stickingto the inner voice despite having no hope for theresuscitation of the patient and the present coercion.’Therefore, by considering these dimensions, managersmust accommodate the basis for the psychological andemotional support for nurses and also engage themin decision-making about providing care to the end-of-life patients through establishing specialized unitsso that there would be the likelihood for providingcomplete care for end-of-life patients.

ACKNOWLEDGEMENTSThis study was supported by the research fund ofthe Tehran University of Medical Sciences (TUMS),Nursing and Midwifery Care Research Center, no. 90-02-99-13666. The authors appreciate all the participantsof the study for their cooperation and wish them goodhealth and peace.

WHAT IS KNOWN ABOUT THIS TOPIC

• Nurses play a crucial role in providing care to end-of-life patients and their families.• Intensive care nurses’ experience in providing care to end-of-life patients affect on the kind of care that nurses provide.• There is few published evidence surrounding intensive care nurses’ experience especially within middle eastern countries.



WHAT THIS PAPER ADDS

• Managers must accommodate the basis for the psychological and emotional support for nurses.• Program and models should be developed to engage nurses in decision-making process about providing care to the end-of-life patients.• Establishing specialized intensive care units so that there would be likelihood for providing complete care for end-of-life patients.

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