Guiding the Process of Dying: The Personal Impact on Nurses

Dianne White, MS, RN; Mary Ann Meeker, DNS, RN, CHPN


Journal of Hospice and Palliative Nursing. 2019;21(5):390-396. 

In This Article


This study's aim was to describe the experiences of acute care nurses caring for dying patients and their families as they transitioned to comfort-focused care. Nurses reported how providing this care affected them and identified their strategies for self-support and development of competence. As indicated in the Figure, the sources of distress drove the need for support. The strategies for support provided power to ease the sources of distress. Supported nurses created the energy that resulted in enhanced EOL care and the opportunity for dying to go well. Nurses earned professional fulfillment that enhanced their ability, motivation, and sustained attention to move the gears that tackled the sources of distress for themselves and others. Having experienced the constraints to good EOL care and its intense demands, many participants were motivated to help others develop needed skills.

In a society whose primary focus is curative care, professionals providing EOL care must continue to petition for improved education, communication, and leadership attention. Findings from this study can help raise awareness among nurse leaders in acute care settings and motivate them to create care practices and organizational structures to help nurses meet the challenges of EOL care.

Consistent with our findings, Kaup et al[19] recognized coping approaches that included individual strategies, as well as the importance of supportive colleagues to ease the burden. An interdisciplinary team that includes the pharmacist, physician, and staff development educators can address the challenges of managing analgesia.[20]

In accordance with findings from this study, Efstathiou and Walker[6] described the need for adequate staffing that allows nurse presence in EOL care. Listening is the heart of communication; it requires that the nurse be present and give undivided attention.[21] Leadership's recognition and value of this time commitment can influence the likelihood of appropriate staffing for these scenarios.

Despite the huge contributions of the End-of-Life Nursing Education Consortium since 2000, nurses as well as nursing students continue to express the need for better preparation for the complex demands of providing excellent EOL care in an acute care setting. New educational strategies are needed[22] and should be initiated in prelicensure programs. For example, Jeffers[23] recommended that college professors work to overcome barriers that inhibit opportunities for nursing students to care for dying patients and to utilize diverse clinical sites. Furthermore, well-designed EOL simulations can develop skill and increase confidence in caring for this specialized population.[24]

As new nurses move into practice, preceptors should seek EOL care experiences for them during orientation in their first professional role. In this manner, the new nurse will gain knowledge and expertise while having the support needed to navigate the challenges associated with providing quality EOL care.[25]

An important limitation of this study is that those nurses volunteering to participate were likely those who valued good EOL care and had experienced sufficient support and mentoring to achieve at least a basic level of competence. Nurses who did not self-select into this study may have reported different views and experiences.

Further research examining how acute care nurses effectively toggle between the strikingly different mindsets of curative care versus comfort-focused care could generate guidance for practicing nurses as well as for educators and administrators. It may be that training and application of mindfulness, such as proposed in the G.R.A.C.E. model,[26] would support nurses in making these shifts and in according equal value to both modes of care.

The G.R.A.C.E. model offers nurses a mnemonic device to support compassionately caring for patients and family and may assist in dealing with moral distress.[27] The model suggests that the nurse briefly pause before a patient encounter and internally gather attention, recall intent (such as to relieve suffering, compassionately care for another), attune to self and patient (through both introspection and empathic observation), consider what will truly serve and allow insight to arise, engage with the patient, and then respectfully ending the interaction.