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Intensive care nurses providing end-of-life care in a community hospital.

Background

Patient death in the intensive care unit (ICU) often results from the inability to recover from critical illness and decisions are then made to shift goals of care from recovery to end-of-life care (EOLC). In the majority of cases, EOLC follows a collaborative decision-making process to withdraw or withhold life-sustaining measures/treatment, and focus on pain and symptom management (Downar et al., 2016; Vanderspank-Wright et al., 2018). EOLC is provided during patients' final stages of dying and extends to the care of the body after death and bereavement support for the family (Canadian Nurses Association et al., 2015). As part of this clinical reality, ICU nurses frequently provide EOLC for dying patients and their families.

Extant literature has explored ICU nurses' roles and experiences in providing EOLC. Many studies have described nurses to be actively involved with patients, families and the interdisciplinary team in end-of-life decision-making by organizing patient care conferences and facilitating communication about the patient's changing clinical condition (Bloomer et al., 2013; Peden-McAlpine et al., 2015). While ICU nurses are involved in the end-of-life decision-making, studies have also highlighted that they encounter inter- and intra-professional conflicts due to varying perspectives about prognosis, appropriate treatments and goals of care for the patient (Coombs et al., 2012; International Nurses' End-of-Life Decision-Making in Intensive Care Research Group, 2015).

Other studies have explored ICU nurses' roles after a decision to shift goals of care to a palliative focus. These studies reveal nurses to enact the withdrawal of life-sustaining treatments and to intently provide care that conserves the dignity of the dying patient (Coombs et al., 2015; Efstathiou & Walker, 2014; McMillen, 2008). Findings from these studies also reveal that nurses experienced elements of uncertainty, as well as emotional labour associated with the care of dying patients and their families (Coombs et al., 2015; Efstathiou & Walker, 2014).

Understanding of ICU nurses' role and experiences in providing EOLC has been informed largely by studies conducted in teaching hospitals. Although there are ICUs in community hospitals, only a few studies have included community hospitals or have been exclusively conducted in such contexts.

One study by Gelinas et al. (2012) explored the stressors experienced by nurses while providing EOLC and palliative care in the ICU setting. Using a descriptive qualitative design, nurses were sampled from ICUs of five hospitals (specifically four teaching and one community) in Quebec, Canada. One of the stressors identified in the study related to nurses describing how they needed more training in end-of-life and palliative care, and more direction (i.e. protocols) to help manage symptoms and overall care. However, this study did not differentiate between those who practised in teaching hospitals and those of community hospitals. Yet, the different hospital contexts may influence the role of education and training, as well as protocols to support the provision of EOLC in ICUs.

To address the community hospital context, a study was conducted by Sarti et al. (2014) in which they designed and implemented a needs assessment to identify gaps in caring for critically ill patients in a community hospital in Ontario, Canada. A mixed method design was employed to identify intra-hospital needs, as well as inter-hospital needs between the community hospital and a referral hospital where patients could be transferred. A further publication by Sarti et al. (2015) based on the critical care needs assessment in the community hospital revealed gaps in the provision of palliative care. Factors that influenced the provision of palliative care included physician availability, frequent transfers to other facilities, and the priority of caring for critically ill patients. Sarti et al. (2015) described how physicians and nurses held differing perceptions in regards to the timing, as well as roles and responsibilities associated with initiating and/or leading goals of care discussions with patients and families. Because of these differing perceptions, discussions and decision-making about shifting goals of care to EOLC occurred inconsistently. The findings from the study by Sarti et al. (2015), in part, suggest that physicians and nurses in the community ICU context may view EOLC differently (both philosophically and practically), as compared to their counterparts in ICUs of teaching hospitals.

Considering the limited and inconclusive evidence, there is a need for further exploration of the community ICU context, in particular nurses' roles and experiences, as they spend the most time with the dying patients and their families.

Nursing in community hospitals through a nursing geography lens

A nursing geography lens is relevant in considering nurses' experiences providing EOLC in the community ICU context. Broadly speaking, nursing geography is an area of scholarship that focuses on exploring the relational dynamics between the profession, and space and place (Andrews & Shaw, 2008; Liaschenko et al., 2011). Notably there is a subset of nursing geography studies that focus on examining the impact of space and place within professional-patient and inter-professional relationships (Andrews & Shaw, 2008; Liaschenko et al., 2011).

The concept of space. The concept of space is viewed as the proximity or distance within the nurse-patient relationship (Liaschenko et al., 2011). Malone (2003) proposes three types of space: physical, narrative, and moral. Physical proximity refers to physical touch and nearness between the nurse and patient through daily nursing care, whereas narrative proximity is relational in nature and implies that the nurse hears and knows the patient's biographical story and meaning of illness, and then relays this knowledge on to others caring for the patient. Moral proximity occurs when the nurse develops both physical and narrative proximity. Moral proximity facilitates gaining knowledge of the patient through physical intimacy and relational connection, and necessarily situates the patient as a person (Malone, 2003). Through engagement with these elements of proximity, the nurse uses this situated knowledge, interprets and takes a moral course of action on behalf of the person (Malone, 2003). These three types of proximity in the nurse-patient relationship are interrelated and time-dependent. Furthermore, Malone (2003) theorized that certain "spatial-structural effects" (p. 2320) or organizational changes can constrain proximity and subsequently, render more distance within the nurse-patient relationship. For instance, Malone (2003) described how reduced length of hospital stay has shortened the time available for nurses to care for patients and eliminated certain traditional nursing practices, such as "backrubs" (p. 2321), which provided nurses an opportunity for assessment as well as providing comfort, and relationship building with the patient. Malone (2003) argued such change has disrupted the levels of proximity, and instead has emphasized efficiency and productivity in nursing work.

Malone's (2003) conceptualization of space brings forth a lens to explore the ways in which nurses are engaged in caring for dying patients and their families in the ICU of the community hospital. Furthermore, it allows for an in-depth examination of the community ICU context as well as the factors that enable or constrain ICU nurses' abilities to provide EOLC.

The concept of place. The concept of place has diverse meanings in nursing geography literature. Carolan et al. (2006) described place as the setting of healthcare services, a healing environment for patients and the social environment that affects nursing care. For this study, the concept of place refers to the community ICU context.

In the province of Ontario, community hospitals are geographically located in areas with populations between 10,000 and 100,000 (outside of large cities) and, as opposed to teaching hospitals, they are generally not associated with the teaching and training of medical students/residents and fellows (Ministry of Health and Long-Term Care [MOHLTC], 2009; Canadian Rural Revitalization Foundation, 2015). As part of a region-wide network of critical care services, many of these community hospitals have ICUs that function as the first point of care to stabilize and to meet some of the physiological needs of critically ill patients. Many ICUs in community hospitals are limited in their ability to provide the full spectrum of critical care services, but are generally able to treat and manage patients post-operatively or with single organ failure using short-term mechanical ventilation (less than 48 hours) (MOHLTC, 2009). If the patient's condition demands further intervention they are then transferred to other facilities (Critical Care Services Ontario, 2015; Sarti et al., 2014).

Often, these community hospital ICUs operate with an open (Gottesman, 2015) model of care, where physicians without specific critical care training (e.g. general practitioners or hospitalists) manage care for patients in the unit. In contrast, ICUs in teaching hospitals frequently use closed (Gottesman, 2015) models of care in which units are staffed by an interdisciplinary team led by intensivists. Whilst ICU models of care are generally based on the type of hospital (community versus teaching), it is also dependent on the region's critical care needs and the resources available (i.e. specialized physicians, nurses, respiratory therapists). Regardless, differences in ICU capacity in services and personnel can have implications to the overall delivery of care (including EOLC) for critically ill patients.

Objective

The objective of this study was to explore nurses' experiences with EOLC in an ICU of a community hospital. Study questions were the following:

1. How do nurses describe their provision of EOLC in the community hospital ICU context?

2. How does nursing geography shape our understanding of nursing care of dying patients in a community hospital ICU?

Methods

Design

This study was conducted using Interpretive Description (ID) as articulated by Thorne (2008). ID is a qualitative research approach with a nursing disciplinary framework geared towards exploring relevant and practical clinical issues, such as the provision of EOLC (Thorne, 2008). The theoretical lens of nursing geography was used to inform the design, the interpretation, as well as the discussion of the findings.

This study was conducted in an ICU of a community hospital located in Ontario. The ICU has less than 15 beds (exact number withheld to protect confidentiality), and serves a mixed medical and surgical, adult patient population with occasional pediatric patients. The unit is equipped to care, on a short-term basis, for patients needing mechanical ventilation. However, limited resources exist and, therefore, patients requiring other interventions such as continuous renal replacement therapy are transferred to a larger centre (often a teaching hospital).

Intensivists managed the medical care of patients admitted to this closed unit. At the time of data collection, the ICU was staffed with fewer than 40 registered nurses (RNs) of which almost two-thirds were employed full-time, and the remainder were part-time and casual. The nurse-to-patient ratio was usually one nurse to two patients, but in situations where patients were mechanically ventilated, the ratio was one to one. On every shift, there were three roles assigned to more experienced nurses: charge nurse, telemetry monitoring and codes. The charge nurse oversaw the delivery of care, while the telemetry nurse was responsible for monitoring up to 10 patients on portable telemetry throughout the hospital. The nurse assigned to codes responded to, and attended critical events, such as cardiac arrest and stroke, throughout the hospital including the emergency department (ED).

Data collection

In this study, the first author (S.W.) was a nurse in a tertiary care teaching hospital and who had previous experiences of providing EOLC in a critical care setting. The first author had no prior relationship to the community hospital, and the agreement with conducting the study followed after the approval from the hospital's research committee and the unit manager.

The first author (S.W.) met with potential participants during scheduled meetings on the unit to introduce the study's overall purposes and the participation required. The first author's (S.W.) business cards were distributed and flyers were posted on the bulletin board in the nursing station to inform nurses of the study. Interested nurses contacted the first author (S.W) via phone or email to discuss the details of the study and to arrange a meeting. Participants were eligible to participate if they met the following inclusion criteria: (1) were a RN working full- or part-time in the ICU of the study hospital; (2) had previous experiences in caring for dying patients in the ICU; and (3) were English speaking.

A purposive sample was employed. Seven RNs agreed to participate. The majority of participants (n = 6) had at least 10 years' experience in critical care and, of these, five had worked (part-time or full-time) in the study ICU for more than 10 years. Almost all participants had completed additional training in critical care (associated with hospital training or college certificates) and had a diploma in nursing as their highest educational level. About half the participants identified that they had received palliative care education either through their formal nursing studies or through seminars.

The data were collected through two sets of face-to-face interviews: an initial and a follow-up. The initial interviews were semi-structured in nature. Participants were asked questions from the guide (Table 2), but were also free to elaborate and to discuss as they wished regarding EOLC. Follow-up interviews were conducted approximately six months after the initial ones, where a summary of the findings was provided to participants, offering them the opportunity to clarify and explore further the findings. All participants were contacted, but only four were available for follow-up interviews.

Interviews were conducted at a private location chosen by the participant. All initial and follow-up interviews were conducted by the first author (S.W), audio-recorded and transcribed verbatim. Then the transcripts were verified for accuracy. Initial and follow-up interviews lasted approximately 60 to 90 minutes depending on participants' articulation of their experiences and the findings shared.

Data analysis

Within the method of ID, data analysis is an iterative process of immersing, analysing and reflecting on the data as it is collected (Thorne, 2008). All authors of the study reviewed the original transcripts, and the first author (S.W) coded the transcribed interview data following the analytic technique Thematic Networks (Attride-Stirling, 2001), where data was organized in a web-like network and patterns and relationships were observed. These patterns and relationships were interpreted and organized into preliminary themes by all authors. Themes were further refined into a thematic analysis, a product of ID and a representation of the participants' experiences that provides a new perspective on the topic of EOLC (Thorne, 2008).

Rigour

Several methods were taken to ensure rigour throughout the study: representative credibility, auditability, and transferability, which were consistent with principles articulated by Thorne (2008), and Polit and Beck (2012). In terms of representative credibility, the first author (S.W.) conducted follow-up interviews where themes were shared with participants. During these interviews, participants were able to confirm, discuss, and challenge whether the findings were representative of their experiences. For auditability, the first author (S.W.) kept a journal, which was used to record important decisions related to data analysis, and as a means for reflexivity. Furthermore, the themes were verified by all authors (F.F.B., K.T., D.W.) who had expertise in critical care nursing and/or qualitative research. Lastly, transferability was also considered. A description of the study setting and basic demographics of the participants allowed readers to discern whether the findings of the study were transferable to other community hospital contexts.

Research ethics approval for this study was obtained from the academic institution Research Ethics Board (H08-16-14) and the community hospital's research committee. Prior to data collection, written informed consent was received from each participant. Pseudonyms were used to maintain participants' confidentiality.

Findings

The analysis of the data revealed an overarching theme of "switching gears." Participants viewed switching gears as an intentional change in the focus from providing life-sustaining medical treatment to EOLC when it was no longer possible to save the patient's life and death was inevitable. Participants' involvement with switching gears included discussions with the interdisciplinary team and patients, achieving consensus, and providing care (i.e. pain and symptom management and comfort measures). The switching of gears created struggles that seem to be related to a community ICU context. This paper discusses participants' struggles, as they relate to transferring patients out of the ICU, needing help to provide care, and wearing multiple hats.

Transferring patients out of ICU

One of the most common "struggles" participants expressed was the frequent transfers of dying patients out of the ICU to the medical floors. All participants viewed private rooms in the ICU to be an ideal space for dying patients and their families to spend their remaining time together. Furthermore, many participants expressed that staying in the ICU allowed the families to benefit from the relationships built with the nurses who knew them. Beth explained, "We [nurses] have a rapport with the patient [and] the family, it's important that they stay in that bed..."

Yet, tensions existed due to limited resources including place and space in the community hospital. For example, participants expressed that often it was not possible to keep the dying patient in the ICU, because they "needed the bed" for another critically ill patient who was often already waiting in the Emergency Department (ED). As such, nurses' prioritization of beds and transferring of patients (particularly dying patients) were frequently out of necessity, and in line with the mandate of the community ICU in stabilizing critically ill patients. Karen discussed a situation where she had to transfer someone to the medical floor. She reflected, "With the acuity of patients [who] are coming in, very seldom ... would a palliative care patient remain in ICU until they die.We transferred a gentlemen out at 1:30 am and he passed away at 5:30, but we needed the bed. So those circumstances are hard too because you kind of uproot the family and have them move"

This quote by Karen demonstrates how transfers affected the space and place in which EOLC was provided. These transfers were seen as a physical displacement and a disruptive relational experience for dying patients and their families, as they were required to move from one unit to another, and to receive care from staff they did not know.

Depending on the situation, participants took certain actions when it came to the transferring of dying patients to the floors. Beth shared how she and her colleagues voiced their concerns to the intensivists and asked for the patient to stay a little while longer in the ICU, especially if they were imminently dying. Beth explained, "We say no, you're not getting that bed yet ... You [intensivists] wanted the patient in ICU ... we sometimes have to advocate, but it's a fight to palliate in the ICU ..." In some instances, nurses were able to successfully advocate for dying patients and their families to stay in the ICU.

For other participants, there was a sense of making the best out of the necessity of transferring dying patients. Emily explained that she and her colleagues collaborated with thebed management department and the nurse manager to arrange a semi-private or private room for the patient. Emily added, "It's an ongoing thing we all know the [palliative] patient will be transferred ... I call bed management, and say, 'if they could please reserve a single or semi-private room for this patient'; and I will [also] ask my manager." A single or semi-private room on the floor was recognized as a better alternative to a four-bed room for dying patients and their families in terms of privacy. Participants' continued advocacy for patients and families and their collaboration with the interdisciplinary team illustrated a desire to facilitate a positive experience despite unfortunate circumstances.

Needing help to provide care

In this community ICU context, there was generally not enough staff to accommodate for one nurse to care for one dying patient and his or her family. As such, participants discussed that it was a normalized practice in the unit for nurses to have a heavier patient assignment if one patient was dying. It seemed that, in assigning patients to staff, the assumption was that a dying patient would require less care than a patient, for example, needing assessments and interventions for ketoacidosis. The nursing staff experienced tensions associated with managing multiple competing priorities. Emily shared a situation when she had such an assignment. I had a patient on BIPAP (bilevel positive air pressure machine) ... very end-stage COPD (Chronic Obstructive Pulmonary Disease), confused ... pulling off everything, then I had this palliative patient in this end, and ... I had a [patient with] DKA (Diabetic Ketoacidosis) across [the unit], which of course you're doing sugars every hour ... the lab work, the drips ... then the other nurses are so busy, that when I want to go in and turn her [palliative patient] and I want to provide her care ... I have no help"

Participants, like Emily, perceived heavy patient assignments to be difficult and frustrating, as they felt they were not able to commit to caring for the dying patient in the same way as their other patients. For instance, in reflection of the heavy patient assignment, Emily voiced, "I just felt so horrible, because this is not how it should be."

Participants discussed the actions they had taken in an effort to cope with a heavy patient assignment. Catherine shared how she tried to reprioritize her care, "Depending on the family and depending on the level of anxiety or what's going on in the palliative room ... I have to tell my other people to wait, if they can. Simple things." For the participants, there seemed to be some flexibility to adjust their priorities in care and to respond accordingly to the situation. However, there also appeared to be limitations as to what could be reprioritized. Catherine mentioned only "simple things", such as baths, could be delayed. Otherwise, nurses had to prioritize meeting the needs of patients who were critically ill.

Sometimes participants described how their colleagues stepped in to help fulfill perceived responsibilities towards dying patients. Melanie described that her colleagues would assist her by "watching" her other patients, while she spent time with the grieving family of the dying patient. She shared, "Our coworkers ... are there to help you ... watch another patient for a little bit, while you go and spend time with that family that need support." Similarly, Emily described her colleagues providing help when a patient had died, and a newly admitted patient arrived to the unit a short time afterwards. In both situations, there was a sense of working together and sharing some of the responsibilities among the nurses to ensure that the dying patients and their families still had their needs met. Yet, this sharing of responsibility was also dependent on the complexity of patient assignments and whether nurses were able to provide help.

Wearing multiple hats--it can be a burden

An additional struggle identified by the participants was related to the multiple roles nurses assumed both within and outside of the ICU in the community hospital context. Because the vast majority of the sample was very experienced RNs, participants described how they had to assume various other roles aside from being at the bedside, such as "charge nurse", "telemetry monitoring" and "codes." Melanie, for example, described her care for two patients on this one particular shift, where she was also the designated person on "codes." She recalled, "My vent [patient in ICU] was sick, but then they had called a code, and I was on codes, so I went down and met T [patient in the ED], and he was quite sick." Melanie shared that she cared for this patient in the ED for some time until the interdisciplinary team decided to move him to the ICU. Because the maximum capacity of the unit to support patients on mechanical ventilation had been reached, Melanie had to return to the unit to transfer her other patient out to a larger teaching hospital. However, at the same time, decisions were made to not proceed with further life-sustaining medical treatments for the other patient in ED, who died shortly afterwards. Melanie reflected, "Even though I'd only met T [patient in the ED] for a brief time, I felt like we had really connected, so I went down to speak with the family and gave my condolences. I had a lot of emotions. I think because I lost T and then my other patient [in ICU] who I had a good rapport with is now being flown away. It's a lot of stress, you worry a lot ... you don't have time to get over it, and then you're getting the next sick patient from the floor ..."

Although Melanie's story focused on the care of the dying patient outside of the ICU, it revealed aspects of a community hospital. In this context, nurses often contended with responsibilities within and outside of the ICU, which meant the place and space in which they provided care was not limited to the ICU. Their relationships with patients and families, as well as their provision of care were impacted. Using the metaphor of 'multiple hats', Emily explained that having more than one role was difficult and a "burden." She elaborated, "We carry more than one hat at a time ... At the end of the day, someone and something gets set aside and that's a big burden ... we're in a variety of roles ... to switch and take on another, it's difficult."

Discussion

The aim of this study was to explore nurses' experiences with providing EOLC in the ICU of a community hospital and to determine how nursing geography shapes our understanding of these experiences. Participants experienced many struggles in "switching gears," particularly in enacting the care of dying patients. These struggles included the transfer of dying patients out of the ICU, needing help to provide care and the taking on of multiple roles. Utilizing a nursing geography lens, it could be seen that there were two factors underpinning participants' struggles: limited physical and human resources and a limited integration of EOLC in the ICU of this community hospital.

Limited physical resources emerged in the form of a finite (fixed) number of beds in the community ICU, which required transferring dying patients out of the unit. Findings showed that participants experienced tension with these transfers, as it disrupted their provision of care and their relationships with these patients and their families. Similar instances of transfers of dying patients due to finite ICU beds in teaching hospitals have also been documented in the literature (Bloomer et al., 2013; Liaschenko et al., 2011). Bloomer et al. (2013), for example, described that nurses experienced conflicted feelings and pressure from others to transfer the dying patient out of the ICU when the dying process appeared prolonged, in order to "free up beds" (p. 25) for other patients.

In the current study, there was limited structure (i.e. no existing protocol or policy) to allow for dying patients to stay in the ICU. As a result, participants took to their own initiative to create space for dying patients by continuing to provide care for them in the ICU, and when not possible, to request a transfer to a private room (on the medical floor) for them. While some of these efforts were successful, transfers of dying patients were beyond participants' control or that of first-line management. The finite beds in the ICU were organized and prioritized at a system level such that incoming critically ill patients from other areas like the ED were accommodated because the community hospital was the first point of care. This also speaks to the community ICU being operationalized as a place primarily to 'save' and treat patients with life-sustaining medical therapies.

Limited human resources also underpinned participants' struggles. Not surprising, extant literature has described that hospitals in small/non-metropolitan communities often face tremendous challenges with human resources (Medves et al., 2013; Rechel et al., 2016). Specifically, nurses working part-time and casual positions result in lack of continuity of staff caring for patients, which has been identified as problematic for nurses and their care of patients in community hospital contexts (Medves et al., 2013). In this current study, limited human resources resulted in heavy patient assignments and multiple roles for nursing staff. These findings are different from some ICUs of teaching hospitals where nurses were able to maintain a one-to-one ratio with dying patients and families, and to spend the necessary time caring for them (Holms et al., 2014). In this study, participants' experiences highlighted how their time to provide quality care (including EOLC) competed with the number of patients, and the responsibilities they had. Heavy patient assignments and multiple roles often interfered with participants' ability to maintain basic physical proximity in their nurse-patient relationships, let alone develop other levels of narrative and moral proximity.

The second factor relating to participants' struggles was a limited integration of EOLC in the community ICU. From the participants' perspective, the physician perceived that dying patients no longer needing the care provided in the ICU could be transferred to the floors. However, there are situations where dying patients need to die within the place of the ICU. For example, death can be imminent within minutes to hours after the withdrawal of life-sustaining treatments (Long et al., 2015). In these situations, in the time remaining, the ICU staff need to build on any nurse-patient relationship already established to provide care to the dying patient and to prepare the family for the death of their loved one.

When dying patients stayed in the ICU, the participants described how staffing arrangements were organized such that they would sometimes have a critically ill patient and a dying patient. This situation resulted in participants having a sense of being pulled in two directions: wanting to support the dying patient and family but needing to meet the needs of critically ill patients. The findings revealed that participants experienced conflicts as they recognized the importance of both life-sustaining treatments and EOLC, but were infrequently able to fulfill their responsibilities simultaneously. This had implications for participants who felt they were not able to commit to the care for the dying patient in the same way as other patients in the unit, especially in terms of meeting their varied needs (including emotional) and spending time with them and their families. Studies conducted in teaching hospitals have similarly described how nurses have felt frustrated and unsupported when there was a lack of understanding of the complexity of providing EOLC and a "strong curative culture" (Ranse et al., 2012, p. 7) in the ICU (Gelinas et al., 2012). While this lack of recognition for the needs of dying patients may occur in various contexts, there are fewer educational and protocol supports in place for staff to integrate EOLC in the community ICU.

Relevance to clinical practice

The participants demonstrated their advocacy role particularly in providing care and trying to keep dying patients in the ICU. However, given the community context, they also had to provide various roles outside of the ICU, which took them away from their patients. If nurses are to provide these additional roles then this should be reflected in the staffing allocation in the community hospital ICU. The focus on the nurse-patient relationship by these experienced nurses must be heeded. The importance of this relationship should not be diminished when examining the role of the nurse in the care provision. This recognition should be factored in when considering additional roles that may be common to the community hospital context to avoid adding competing demands to the nurse's workload.

The current study reveals there is a need to manage finite resources of ICU beds through the development and support of protocols. For example, leaders in both medicine and nursing can examine the criteria by which patients are admitted to ICU. If patients are already palliative then questions should arise as to why they would come to ICU only to be transferred out later. Additionally, leaders can review protocols that limit the transfer of acutely ill patients to other facilities, so that there would be continuity of care for these patients regardless of their illness trajectory.

While the focus on active treatment of patients is essential in the ICU, it can create difficulties for nurses and intensivists to shift goals of care to palliation and EOLC. Nurses and intensivists could benefit from educational support in this area. Improving communication skills, for instance, would facilitate answering questions from family members, participating in family meetings, and discussing end-of-life-related topics (such as code status, advanced care planning and goals of care) (Krimshtein et al., 2011; Smith et al., 2013).

Limitations

Participants sampled in this study were interested in sharing their stories and perspectives with providing EOLC. As such, the findings may not have captured the experiences of other nurses in the community ICU who may have felt uncomfortable with discussing EOLC. Additionally, the majority of participants in the sample were female. Future studies could also explore ICU nurses' experiences among a more diverse sample. This study was also conducted in one community ICU, and so, findings may not reflect the experiences of nurses in other community hospitals.

Conclusion

Nurses in this study have described their efforts to advocate for patients at the end of life, and have shared some of their struggles in the provision of EOLC. With the lens of nursing geography, these struggles revealed that there were underpinning influences in the community hospital ICU context, such as limited resources and limited focus on the needs of the dying patient and family. While these influences are not unique, they do suggest overall that the experiences of nurses' provision of EOLC is complex and multifaceted in community hospital ICUs.

Address for correspondence: Sandra Wong, MScN, CCN(C), CNCC(C), School of Nursing, Faculty of Health Sciences, University of Ottawa, Roger Guidon Hall, 451 Smyth Road, Ottawa, ON, K1H 8L1. Email: swong077@uottawa.ca

Brandi Vanderspank-Wright, PhD RN CNCC(C), Associate Professor, School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, ON

Frances Fothergill Bourbonnais, PhD, Emeritus Professor, School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, ON

Kelley Tousignant, MScN, Continuing Special Appointment Professor, School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, ON

David Kenneth Wright, PhD, CHPCN(C), Associate Professor, School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, ON

Acknowledgements

The authors would like to thank the nurses who participated in this study and shared their important stories and experiences of caring for dying patients and families in the unit. This research study received funding from The Ottawa Hospital Nursing Professional Practice through the Nursing Research Endowment Fund and Nursing Research Catalyst Award.

REFERENCES

Andrews, G. J., & Shaw, D. (2008). Clinical geography: nursing practice and the (re)making of institutional space. Journal of Nursing Management, 16(4), 463-73. https://doi.org/10.1111/j.13652834.2008.00866.x.

Attride-Stirling, J. (2001). Thematic networks: an analytic tool for qualitative research. Qualitative Research, 1(3), 385-405. https://doi. org/10.1177/146879410100100307

Bach, V., Ploeg, J., & Black, M. (2009). Nursing roles in end-of-life decision making in critical care settings. Western Journal of Nursing Research, 31(4), 496-512. https://doi. org/10.1177/0193945908331178

Bloomer, M. J., Morphet, J., O'Connor, M., Lee, S., & Griffiths, D. (2013). Nursing care of the family before and after a death in the ICU- An exploratory pilot study. Australian Critical Care, 26(1), 23-28. https://doi.org/10.1016/j. aucc.2012.01.001

Brooks, L. A., Manias, E., & Nicholson, P. (2017). Barriers, enablers and challenges to initiating end-of-life care in an Australian intensive care unit context. Australian Critical Care, 30(3), 161-166. https://doi.org/10.1016Aj. aucc.2016.08.001

Calvin, A. O., Kite-Powell, D. M., & Hickey, J. V. (2007). The neuroscience ICU nurse's perceptions about end-of-life care. Journal of Neuroscience Nursing, 39(3), 143-150.

https://journals.lww.com/jnnonline/Abstract/2007/06000/ The_Neuroscience_ICU_Nurse_s_ Perceptions_Ab out.4.aspx

Canadian Nurses Association, Canadian Hospice Palliative Care Association, & Canadian Hospice Palliative Care Nurses Group. (2015). Joint position statement. The palliative approach to care and the role of the nurse. https://www. cna-aiic.ca/~/media/cna/page-content/ pdf-en/the-palliative-approach-to-careand-the-role-of-the-nurse_e.p df

Canadian Rural Revitalization Foundation. (2015). State of rural Canada report. http://sorc.crrf.ca/

Carolan, M., Andrews, G. J., & Hodnett, E. (2006). Writing place: A comparison of nursing research and health geography. Nursing Inquiry, 13(3), 203-219. https://doi.org/10.1111/ j.1440-1800.2006.00322.x Coombs, M. A., Addington-Hall, J., & Long-Sutehall, T. (2012). Challenges in transition from intervention to end of life care in intensive care: A qualitative study. International Journal of Nursing Studies, 49(5), 519-527. https://doi. org/10.1016/ j.ijnurstu.2011.10.019

Coombs, M., Fulbrook, P., Donovan, S., & Tester, R. (2015). Certainty and uncertainty about end of life care nursing practices in New Zealand intensive care units: A mixed methods study. Australian Critical Care, 28(2), 82-86. https://doi.org/10.1016/ j.aucc.2015.03.002

Critical Care Services Ontario. (2015). Ontario Critical Care Plan 2015-2018. https://www.criticalcareontario.ca/ EN/AboutUs/Strategic%20Direction/ Ontario%20Critical%20Care%20 Plan%20(2015%20-%202018)/Pages/ default.aspx

Downar, J., Delaney, J.W., Hawryluck, L., & Kenny, L. (2016). Guidelines for the withdrawal of life-sustaining measures. Intensive Care Medicine, 42(6), 1003-1017. https://doi.org/10.1007/ s00134-016-4330-7

Efstathiou, N., & Walker, W. (2014). Intensive care nurses' experiences of providing end-of-life care after treatment withdrawal: A qualitative study. Journal of Clinical Nursing, 23(21), 3188-3196. https://doi.org/10.1111/ jocn.12565

Endacott, R., Boyer, C., Benbenishty, J., Nunn, M. B., Ryan, H., Chamberlain, W, Boulanger, C., & Ganz, F. D. (2016). Perceptions of a good death: A qualitative study in intensive care units in England and Israel. Intensive and Critical Care Nursing, 36, 8-16. https:// doi.org/10.1016/j.iccn.2016.04.004

Gelinas, C., Fillion, L., Robitaille, M. A., & Truchon, M. (2012). Stressors experienced by nurses providing endof-life palliative care in the intensive care unit. Canadian Journal of Nursing Research, 44(1), 18-39. http://europepmc.org/abstract/med/ 22679843

Gottesman, R. (2015). Committee on specialties review. Critical care medicine (adult and pediatric) 2015. http:// www.canadiancriticalcare.org/_assets /5.FINAL_CriticalCareMedicine_COS_ Response_2015-02-06.pdf

Holms, N., Milligan, S., & Kydd, A. (2014). A study of the lived experiences of registered nurses who have provided end-of-life care within an intensive care unit. International Journal of Palliative Nursing, 20(11), 549-556. https://doi. org/10.12968/ijpn.2014.20.11.549

International Nurses' End-of-Life Decision-Making in Intensive Care Research Group, Gallagher, A., Bousso, R. S., McCarthy, J., Kohlen, H., Andrews, T., Paganini, M. C., Abu-El-Noor, N. I., Cox, A., Haas, M., Arber, A., Abu-ElNoor, M. K., Baliza, M. F., & Padilha, K. G. (2015). Negotiated reorienting: A grounded theory of nurses' end-of-life decision-making in the intensive care unit. International Journal of Nursing Studies, 52(4), 794-803. https://doi. org/10.1016/j.ijnurstu.2014.12.003

Krimshtein, N. S., Luhrs, C. A., Puntillo, K. A., Cortez, T. B., Livote, E. E., Penrod, J. D., & Nelson, J. E. (2011). Training nurses for interdisciplinary communication with families in the intensive care unit: An intervention. Journal of Palliative Medicine, 14(12), 1325-1332. https://doi.org/10.1089/jpm.2011.0225

Liaschenko, J., Peden-McAlpine, C., & Andrews, G. J. (2011). Institutional geographies in dying: Nurses' actions and observations on dying spaces inside and outside intensive care units. Health & Place, 17(3), 814-821. https://doi. org/10.1016/ j.healthplace.2011.03.004

Long, A. C., Muni, S., Patsy, T. D., Engelberg, R. A., Nielsen, E. L., Fitzpatrick, A. L., & Curtis, J. R. (2015). Time to death after terminal withdrawal of mechanical ventilation: Specific respiratory and physiologic parameters may inform physician predictions. Journal of Palliative Medicine, 18(12), 1040-1047. https://doi.org/10.1089/ jpm.2015.0115

Malone, R. E. (2003). Distal nursing. Social Science & Medicine, 56(11), 2317-2326. https://doi.org/10.1016/ S0277-9536(02)00230-7

Medves, J., Edge, D. S., Bisonette, L., & Stansfield, K. (2015). Supporting rural nurses: Skills and knowledge to practice in Ontario, Canada. Online Journal of Rural Nursing and Health Care, 15(1), 7-41.

McMillen, R. E. (2008). End of life decisions: Nurses perceptions, feelings and experiences. Intensive and Critical Care Nursing, 24(4), 251-259. https://doi. org/10.1016/j.iccn.2007.11.002

Ministry of Health and Long-Term Care. (2009). Hospitals. Public Hospitals Act. Loi sur les hopiteau publics. http://www. health.gov.on.ca/en/common/ system/ services/hosp/hospcode.aspx

Noome, M., Dijkstra, B. M., van Leeuwen, E., & Vloet, L. C. (2016). The perspectives of intensive care unit nurses about the current and ideal nursing end-of-life care. Journal of Hospice & Palliative Nursing, 18(3), 212-218. https://doi. org/10.1097/NJH.0000000000000221

Peden-McAlpine, C., Liaschenko, J., Traudt, T., & Gilmore-Szott, E. (2015). Constructing the story: How nurses work with families regarding withdrawal of aggressive treatment in ICU-A narrative study. International Journal of Nursing Studies, 52(7), 1146-1156. https://doi.org/10.1016Zj. ijnurstu.2015.03.015

Polit, D. & Beck, C. (2012). Nursing research. Generating and assessing evidence for nursing practice. Lippincott Williams & Wilkins.

Ranse, K., Yates, P., & Coyer, F. (2012). End-of-life care in the intensive care setting: A descriptive exploratory qualitative study of nurses' beliefs and practices. Australian Critical Care, 25(1), 4-12. https://doi.org/10.1016/j. aucc.2011.04.004

Rechel, B., Dzakula, A., Duran, A., Fattore, G., Edwards, N., Grignon, M., Haas, M., Habicht, T., Marchildon, G. P., Moreno, A., Ricciardi, W., Vaughan, L., & Smith, T. A. (2016). Hospitals in rural or remote areas: An exploratory review of policies in 8 high-income countries. Health Policy, 120(7), 758-769. https://doi.org/10.1016/ j.healthpol.2016.05.011

Sarti, A. J., Fothergill-Bourbonnais, F., Landriault, A., Sutherland, S., & Cardinal, P. (2015). An interhospital, interdisciplinary needs assessment of palliative care in a community critical care context. Journal of Palliative Care, 31(4), 234-242.

Sarti, A. J., Sutherland, S., Landriault, A., Fothergill-Bourbonnais, F., Bouali, R., Willett, T., Hamstra, S. J., & Cardinal, P. (2014). Comprehensive assessment of critical care needs in a community hospital. Critical Care Medicine, 42(4), 831-840. https://doi.org/10.1097/ CCM.0000000000000036

Smith, L., O' Sullivan, P., Lo, B., & Chen, H. (2013). An educational intervention to improve resident comfort with communication at the end of life. Journal of Palliative Medicine, 16(1), 54-59. https://doi.org/10.1089/jpm.2012.0173

Thorne, S. (2008). Interpretive design. Left Coast Press, Inc.

Vanderspank-Wright, B., Roze des Ordons, A. & Hartwick, M. (2018). Introduction to goals of care. In P. Cardinal, T. Witter, & S. Yamashita (Eds.), Navigating medical emergencies: An interactive guide to patient management. (Goals of Care). http://navme.royalcollege.ca/ebook-epro d/EN/imap.shtml#34

By Sandra Wong, Brandi Vanderspank-Wright, Frances Fothergill Bourbonnais, Kelley Tousignant, and David Kenneth Wright

Wong, S., Vanderspank-Wright, B., Fothergill Bourbonnais, F., Tousignant, K, & Wright, D. K. (2020). Intensive care nurses providing end-of-life care in a community hospital. The Canadian Journal of Critical Care Nursing, 31(3), 23-30.
Table 1. Implications for nurses

* Study findings provided insight to nurses' experience
and particularly, the struggles they faced while providing
EOLC in an ICU of a community hospital.

* Underpinning these struggles were factors of limited
(physical and human) resources and a limited focus on the
needs of the dying patient and family in this context.

* Implications from this study merit further exploration in
the way in which resources are optimally managed and
how this impacts EOLC

Table 2. Guide for initial semi structure interviews
Questions

* Please describe your experiences in caring for dying
patients on your unit and provide some examples.

* Can you please describe how it is you are involved in
providing end-of-life care (EOLC)?

* Please describe what good EOLC means to you.

* Are there any barriers to you providing EOLC on your
unit? Please elaborate.

* Are there any facilitators that assist you in providing EOLC
in your unit? Please elaborate.

* Are there EOLC situations that you felt have gone well? Or
EOLC situation that could have improved? Please explain.

* If you were given the opportunity to make changes, how
would you like to see EOLC provided to patients on your unit?

Probing Questions

* What is it like to practise in a community critical care
unit? How does it compare to your other critical care
experiences?

* Have you practised EOLC in any other critical care setting?
Please share your experiences. How are these experiences
differing or alike from your experiences of providing
EOLC in this unit?

* Is there anything else you would like to add?
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Author:Wong, Sandra; Vanderspank-Wright, Brandi; Bourbonnais, Frances Fothergill; Tousignant, Kelley; Wrigh
Publication:The Canadian Journal of Critical Care Nursing
Article Type:Report
Geographic Code:1CANA
Date:Dec 22, 2020
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