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descriptive study of coping strategies used by edical Intensive Care Unit nurses during

ransitions from cure- to comfort-oriented care

ames M. Badger, PhD, APRN, BC, Providence, Rhode Island

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OBJECTIVE: The aim of this study was to describe Medical Intensive Care Unit (MICU) nurses’ coping behaviors while caring for a patient whose medical treatment transitioned from cure- to comfort- oriented care.

METHODS: The use of a descriptive qualitative research design with brief selective participant obser- vation and focus group interviews was used to explore the coping experiences of MICU nurses. The study took place in an 18-bed MICU that was part of a 719-bed acute care hospital located in the northeastern United States. Nineteen female and 5 male nurses participated in the study.

RESULTS: MICU nurses used a variety of coping strategies including cognitive, affective, and behavioral techniques to cope with end-of-life care transitions. Being a MICU nurse in and of itself provided a sense of pride for staff. Most believed that their clinical opinions were valued and that they were respected as professionals. Providing futile care, the perception of “torturing the patient,” and conflict with families caused the greatest distress to staff.

CONCLUSIONS: MICU nurses are dynamic and resourceful when responding to challenging end-of- life patient care situations. (Heart Lung® 2005;34:63-8.)

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roviding end-of-life care to patients in the Medical Intensive Care Unit (MICU) often re- quires dramatic shifts in attitudes and thera-

eutic interventions. This is especially true as inten- ive care unit (ICU) staff transition from extending ife to allowing life to end. Nurses are routinely nvolved in social negotiations about maintaining r withdrawing life-support treatment. Implement-

ng this type of change in therapeutic goals may ccur as a single, complete change in direction or ay occur with time as specific life-support treat- ents are gradually discontinued.1

Providing nursing care to patients dying in the ICU requires a conscious move from the “rescue” ode to approaches that recognize death’s inevita-

rom the Departments of Nursing and Psychiatry, Rhode Island ospital, Providence, Rhode Island.

eprint requests: James M. Badger, PhD, APRN, BC, Rhode Island ospital, 593 Eddy St., APC 608B, Providence, RI 02903.

147-9563/$ – see front matter opyright © 2005 by Elsevier Inc.

n10.1016/j.hrtlng.2004.08.005

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ility and subsequent refocusing efforts on provid- ng comfort-care. There is, however, a paucity of nowledge regarding how MICU practitioners expe- ience this turning point or exploring the more per- onal dimensions of ICU nursing, specifically, the sychological sequaele of MICU staff members as hey impacted are during the transition from pro- iding life-saving care to providing life-ending care. he use of a descriptive qualitative research design ith brief selective participant observation and fo- us group interviews was used to explore the coping xperiences of MICU nurses.

EVIEW OF THE LITERATURE Coping behavior can be defined as the innate,

aturally occurring personal response by an individ- al confronted with a stressful situation.2 Maloney nd Bartz3 explored the personality and coping haracteristics of ICU versus non-ICU staff. ICU urses were found to be more adventurous, felt less owerful, and were viewed as more “detached” than

on-ICU nurses. Chapman4 found that nurses who

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ad consistent access to social support systems xperienced less frustration and stress associated ith providing care in the ICU setting. Adaptive oping techniques commonly included defensive ehaviors such as cheerful denial, non-sense busi- esslike manners (isolation), passive withdrawal, umor, and— occasionally—angry outbursts.

There were, however, constraints placed on the xpression of anger by the situation and the group t large.5 Staff members learn to suppress or repress vert hostility. Habituation is both inevitable and ecessary if critical care nurses are to adapt to the

CU environment. According to Hay and Oken,5

staff must maintain an underlying alertness to dis- ern and respond to cues which may have special eaning” (p. 111). Other adaptive coping behaviors

ncluded talking things out, active mastery of com- lex technical procedures, and drawing on mutually hared past experiences.6 Maladaptive coping be- aviors were exemplified by emotional withdrawal nd avoiding the patient, fostering overdependence, cting out (calling out sick, coming in late, or not ompleting assignments), focusing on equipment or echnical aspects of care, projection, denying or epressing all feelings, or excessive treatment such s too frequent monitoring.7

Staff members commonly develop behaviors to aintain a professional demeanor during their inter-

ctions with dying patients and bereaved family mem- ers. It is not uncommon for nurses to physically nd/or emotionally distance themselves once it has ecome clear that the patient is going to die. Conboy- ill8 attributed this distancing behavior as related to oth a lack of preparation for death and to self-pro- ection. Irritation and frustration are common reac- ions among staff members who lose a patient. Mis- anagement of these emotions can set up defensive

arriers to the vulnerability and sadness individuals eel but wish to avoid.9 Siegel10 summed the matter p by saying, “dealing with people, as opposed to aring for people, leads to depersonalization and pain or everyone” (p. 659). Failure to define a personal role n caring for the dying patient and his or her family

ay make it difficult for nurses to truly become in- olved or perhaps derive personal satisfaction from heir experience.11

Davies et al.12 reported that nurses experience rief distress when they realize the inevitability of a atient’s death but must continue with the realities f an active treatment regimen. Providing palliative are in the acute care setting may seem contrary to heir normal curative focus and cause role strain. nterpersonal distress may result from inconsisten-

ies related to beliefs, values, opinions, knowledge, m

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r actions that are incongruent. Additionally, the urses’ personal values, knowledge, and behaviors ay be in direct opposition to those of colleagues

r in conflict with the interests of other people. irchhoff and Beckstrand13 reported that “nurses do ot acknowledge having difficulty providing care to ying patients aside from conflicts that arise be- ause of families and physicians” (p. 96).

The hour-by-hour patient care responsibilities com- only fall directly on the nursing staff. There is a

onstant demand on the nurse’s productivity and ef- ectiveness. Additionally, dying patients may create eelings of inadequacy for nurses. This may happen hen the nurse’s perceived inadequacy conflicts with is or her idealized role of being a professional who an deal effectively with any injury or disease. Nurses ay focus on emphasizing problems associated with

ying patients as a means to displace these uncom- ortable feelings of inadequacy.14

Lipp15 believed that “qualities that give [ICU urses] great emotional strength at working with he acutely ill tend also to make them intolerant of atients with weak spirit.” Specifically, “intensive are unit nurses are often least effective with long- tay or patients with chronic problems” (p. 41). Per- eptual change, however, may facilitate nurses with uccessful grieving.16 Eakes17 found that clearly es- ablishing new treatment goals, i.e., shifting from urative to palliative focus, assisted nurses in their rief. The study was based on nurses in a palliative are setting, and thus it is not known if acute care urses would have the same experience.

Spencer18 explored how nurses dealt with their own rief when a patient died on an ICU and what factors elped them effectively overcome their grief. The data ere obtained from survey questionnaires completed y 72 nurses. In-depth interviews were also carried out ith 10 nurses to more fully explore their question- aire responses. The investigator found that nurses xperienced a variety of feelings—including sadness, hock, anger, and relief—when a patient dies. Only a ew nurses reported feeling guilty after a patient death. urses reported that they received peer support in the

orm of informal discussions with colleagues. The re- ults revealed that the majority of nurses had no ormal training in the area of death and dying. Last, urses believed that chatting informally with peers as an adequate means for obtaining support after a atient death. Although these data are interesting, the urvey method of data collection was limiting. It is nclear how the in-depth interviews were performed r who was selected to participate in the interviews. here was also no exploration of what “peer support”

eant or what issues were commonly discussed.

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Saunders and Valente19 reported that most urses believed that they managed their grief better

f they helped a patient die a “good” death. They efined a good death as having the following char- cteristics: (1) the nurse had relieved the patient’s istress and symptoms to the best of her or his nowledge and use of current resources; (2) the atient had the opportunity to reach closure with

mportant relationships; (3) the nurse believed that e or she had delivered the best quality of care for he patient; (4) the patient’s death did not violate atural order (referring to age at time of death;, and 5) the death was contextually appropriate (ex- ected given the circumstances).

ETTING AND PARTICIPANTS The aim of this study was to describe MICU

urses’ coping behaviors while caring for a patient hose medical treatment transitioned from cure- to omfort-oriented care. The study took place in an 8-bed MICU that was part of a 719-bed acute care ospital located in the northeastern United States. ICU nurses were specifically selected for this study

ecause of their first-hand knowledge of working ith critically ill patients and subsequently high

ikelihood of experiencing the dying process of pa- ients. Nineteen female and 5 male nurses partici- ated in the study.

ata collection The nurse researcher and an assistant group

oderator collected the data. The male nurse re- earcher was an experienced consultation-liaison sychiatric advanced practice nurse with group psy- hotherapy training. The group moderator was a emale doctorally prepared cultural anthropologist ith extensive focus-group experience.

Focus group interviews, informal conversations, nd selective participant observation were all used o gather the emic perspective of MICU staff. “Hang- ng out” on the MICU, observing nurses in action, nd actively listening to staff conversations pro- ided a wealth of collateral data. Observations were onducted during a 6-week period before conduct- ng focus-group sessions and included nurses rep- esenting all shifts.

All participants were asked to complete a brief regroup questionnaire. This data was complied nd used to provide aggregate descriptive informa- ion about the personal characteristics of the MICU taff including age, sex, ethnic origin, marital status, ighest level of nursing education, years in general

ursing, and years of experience in critical care. t

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Focus-group interviews were recorded with au- iotape and brief written notes. Audiotapes were ranscribed verbatim after each group session by a rofessional transcriber. The group size averaged etween 4 and 5 participants/session. To allow flex-

bility of attendance, 5 group sessions were offered t different times during the 6-week period. Group nterview sessions were held in the MICU confer- nce room so staff members could remain near ritically ill patients while on duty.

thical considerations There was the possibility that participants

ould experience some emotional discomfort hen discussing their clinical experiences with ritically ill patients. However, it was not expected hat staff would become emotionally over- helmed or experience significant psychological ymptoms as a result of these discussions. None- heless, participants who reported significant dis- ress would be encouraged to seek professional ounseling through a referral to the hospital’s mployee assistance program.

nalysis The analysis process consisted of compiling de-

ographic data from all participants, transcribing udiotape recordings of group sessions, and review- ng data obtained from observational field notes. his analysis began as the data were being gathered nd was a continuous process throughout the data ollection period. The process for the analysis of ranscripts and audiotapes generally followed the ethod described by Miles and Huberman,20 who

ivided the process of analysis into 3 major phases ncluding data reduction, data display, and conclu- ion drawing.

First, the massive amount of data was organized nto initial categories that were pre-established ased on the research questions. This data reduc- ion process required the researcher to make deci- ions about how the data would be emphasized, inimized, or set aside completely to better focus

n the purposes of the research investigation. hroughout this process, however, the researcher emained open to the discovery of new meanings hat might emerge unexpectedly from the data. ext, data display provided the opportunity to fur-

her organize the data by compressing information o facilitate conclusion drawing. This was accom- lished by developing a chart that provided a new ay of arranging and thinking about the more tex-

ually embedded data. This data-display process

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llowed the researcher to discern systematic pat- erns and interrelationships. Charting enabled the esearcher to develop more refined levels of cate- ories and themes as they emerged from the data.

The last phase of the data analysis process is hat Miles and Huberman20 referred to as “conclu- ion drawing.” This involved the researcher stepping ack to consider what the analyzed data meant and o assess its implications for the original research uestions. Simultaneously, verification involved the ross-checking or revisiting of data to verify any mergent conclusion as being true.

The group moderator assisted with the primary nalysis of data. The assistant moderator performed n independent review based on the suggestion of rawford and Acorn.21 Discussion by both parties erved to verify the themes, patterns, and catego- ies. Additionally, as recommended by McDaniel nd Bach,22 researchers returned to the audiotapes o validate the categories based on voice inflection nd content. This process was repeated after leaving he information alone for several weeks. This fresh ook after a period of absence from the data was hought to help in decreasing the number of cate- ories caused by overlapping data.

INDINGS emographic data Twenty-four of 44 MICU nurses, comprising 19

emale and 5 male participants, took part in this esearch investigation. One participant did not com- lete the demographic questionnaire. For the re- ainder of group participants, the mean age for the

roup was 38.7 years (range 24 to 57). Fourteen urses were married, 8 were single, and 1 was di- orced. All of the group participants were white. Of he group, 13 had a bachelor’s of science degree in ursing; 7 had an associate’s degree in nursing; and had a nursing diploma degree. Years in the nurs-

ng profession ranged from 1 to 35 years (mean 3.37). Similarly, the range of experience in MICU ursing varied from 1month to 35 years (mean 9.44).

oping strategies Nurses used a wide variety of different coping

trategies to deal with complex patient care situa- ions occurring on the MICU. These strategies were nitially described in terms of general thoughts and ctions but were later divided into 3 major catego- ies including cognitive, affective, and behavioral echniques. Cognitive strategies included “putting p with it,” visualizing, learning from experience,

eminiscing, and putting things into perspective. d

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utting up with it referred to the belief that “in ssence it’s coming [death] so it’s just a matter of ime. It’s just eight or it’s twelve hours�knowing in he end it’s not going to make a bit of difference what we do].”

Visualizing was a technique used to remain em- athetic. One nurse reported, “I just kept picturing y brother, my sister, my mother there [in bed] and

t kind of gave empathy toward the family and the atient. I always tell myself that it’s a very hard ecision to make.” Learning from experience, “You

ncorporate different things into your nursing [prac- ice]. Kind of look for things or kind of pick up on omething from [the] family’s experiences.” Addi- ionally, “you appreciate life more because it could e us one day.” Visual images are often used as a eans to help “you remember what you’re taking

are of � it gives you empathy.” When nurses look at heir critically ill patients, they do not see the same mage that the family is holding on to; placing a ecent photograph in the room helps nurses to “per- onalize a patient.”

Reminiscing was a process of remembering past atient care experiences. One participant stated, Every now and then we’ll talk about somebody eally sad. We talk about if we did our best. We still alk about patients from years ago that we remem- er, [especially] if there’s somebody with the same isease.” For example, “the guy who worked for his

amily, had two kids, just bought a boat, has leuke- ia and dies.” Last, putting things into perspective

eferred to “do your best not to take it personally. ou don’t take it home with you. You leave it.”

Affective strategies included laughter, externaliz- ng feelings, and emotionally compartmentalizing. everal group participants stated, “we laugh a lot” nd have a “sick sense of humor, making jokes out f what are in reality dreadful situations.” Laughter

s often used to mitigate the tension that results rom toxic interactions with “pain-in-the-ass fami- ies and patients.” For example, “we’ll go into the ackroom” and “say that the family is full of a bunch f nuts � they are all crazy.” Occasionally, the staff ill capitalize on an event that happened on the nit. This was exemplified when “someone com- lained about us, we looked like we never ironed ur uniforms. So the night shift made a bunch of ut-out ironing boards and hung them from the eiling [in our break room].”

However, there were clear boundaries about what opics were considered off limits for humor. Many taff members stated, “[we] never joke about some- hing serious” and, in particular, “not about ‘unfair’

eaths, deaths of young or endearing patients.” Ex-

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ernalizing feelings allowed nurses to “verbalize to ach other” or have a “group session.” This was articularly beneficial when dealing with difficult atients and families. The “group session” provided safe place to air complaints as well as a forum for

eeking aid from peers, such as by stating, “I won’t ake that patient back tomorrow.” In response, col- eagues would offer to be assigned to that patient he next day. Most nurses reported, however, “it’s ot that patient nine out of ten times [that is the roblem] � it is [dealing with] the family.” Thus, everybody rotates through and takes their turn” ith difficult families. Colleagues and peers pro- ided the main audiences for gripes, frustrations, nd target for voicing difficult feelings.

Most nurses acknowledged, “I really don’t talk bout my job a lot when I get home because I feel ike a lot of [what happens on the unit] is just a big owner for everybody else that’s going to listen to e.” One nurse said, “You do what you have to do to

nternalize it. Just kind of separate yourself. People on’t want to hear, well, ‘I terminally extubated omeone today.’ People don’t talk about that stuff � so you] kind of keep that to yourself.”

Behavioral strategies included retreating, avoid- ng, and distancing behaviors. Retreating referred to eing “fired” or dismissed from the patient care ssignment as well as having to just “walk away” for easons of personal frustration or distress. Being ired was a relatively common experience for MICU taff members. It usually occurred “not because you aid anything worse than the person before you � it as just the last time that the person wanted to ear it for whatever reason. That’s okay, somebody lse takes over.”

In addition to more formal coping strategies, urses also reported that the use of faith, existential eliefs, and mutual support were beneficial. Most articipants commented, “We really have a great roup up here because we deal with life and death. e’re all pretty close with each other. Everyone here

as been through it [caring for the dying patient and rieving family] so they know [what it is all about].”

Distancing behaviors were commonly used to get break from overbearing families. One nurse stated,

It’s amazing how much stress you get rid of when ou get [the family] out of the way. You close the oor, get them out of the room, out of your personal pace, and do things with your patient.” Being an ICU nurse also provided a sense of pride for staff.

everal nurses commented, “You know that your pinions are valued” and you are “more respected here in the MICU].” They were proud that their

articular unit was “nationally recognized for our m

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uality of end-of-life-care” and they held themselves o a “very high standard.” Last, one nurse stated, One thing that attracts me to this job is the fact hat nobody else would want to do it. If I can work in his place � that’s kind of cool because other people an’t do it.”

Nurses commonly cited providing futile care and he perception of “torturing the patient” as 2 of the ore distressing situations that they encounter hile providing care on the MICU. Many nurses tated, “the hardest thing to do is keep intervening ith a patient whose is clearly dying so as to pre- ent a natural death.” Most staff acknowledged that we have the technology to keep people alive forever we keep going on and on” � ultimately, “quality [of ife] becomes the issue.” The experience of “tortur- ng the patient” was exemplified by one nurse who tated, “I feel like I am torturing the patient, keeping homever alive beyond their time not for the pa-

ient or what the patient would want, but for other eople � because the family can’t let go.” Many urses felt “you’re not prolonging life �but rather

ust prolonging misery.” Another difficult clinical situation involved facil-

tating communication between families and medi- al staff. Nurses reported being frustrated by “going orth causing discomfort to the patient when some- imes the physicians needed to be a little more ggressive in talking with the family and being hon- st on what the outcome will be.” Yet another nurse emarked, “sometimes you just don’t get the answer ou want.”

Although some focus group discussions were motionally intense, no research participant expe- ienced sustained emotional distress to warrant re- erral for formal psychological treatment. This type f emotional response was not unexpected based n prior experience with other critical care nurses. taff members generally appreciated the opportu- ity to talk about their work-related clinical experi- nces and reactions.

ISCUSSION Nurses commonly used a variety of coping behav-

ors to maintain a professional demeanor during their nteractions with patients, other health professionals, r family members. Staff commonly acknowledged hat personal grief reactions were experienced but not iscussed overtly unless the death involved a young or ndearing patient. Consistent with Kirchhoff and Beck- trand13 and Davies et al.,12 these nurses reported ifficulty when providing care to dying patients, pri-

arily as the result of conflicts that arose because of

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amilies and physicians. Indeed, futile care and the erception of “torturing the patient” caused the great- st amount of distress for staff.

MICU nurses commonly believed that emotional eactions to patient care situations were best shared ith one’s own MICU colleagues. They usually did not hare their work-related experiences with family mem- ers; they avoided “outsider” emotional support and id not seek referral for professional counseling ser- ices. This was consistent with the findings of Spen- er18 that nurses often believed that chatting infor- ally with peers was an adequate means for obtaining

motional support.

tudy limitations The major limitation of this research investigation

as that the experiences of staff members of this articular MICU might be unique to this unit and not eflective of the views or experiences of other MICU taff. This MICU was a unique environment for several easons: (1) the staff had worked together for many ears, and the nurse leaders group worked closely with hem and (2) the unit medical director was involved ith research about end-of-life issues. Together these

actors may have had an impact on how the nurses ealt with end-of-life concerns or at least have influ- nced their beliefs. The entire sample was composed f white nurses and, as such, this may have restricted ny opportunity to obtain end-of-life viewpoints from ther cultural perspectives.

ONCLUSIONS MICU nurses used a variety of personal coping

trategies when confronted with the emotional de- and of complex patient care situations. These cop-

ng strategies were comprised of a combination of ognitive, affective, and behavioral techniques. Nurses sed several cognitive strategies that included “put- ing up with it,” visualizing, learning from the experi- nce, reminiscing, and putting things into perspective. aughter, externalizing, or internalizing feelings were elpful affective strategies used to control distress. ehavioral strategies consisted primarily of retreating, voidance, or selective distancing behaviors. Being a ICU nurse in and of itself provided a sense of pride

or staff. Most believed that their clinical opinions ere valued and that they were respected as profes- ionals. MICU nurses are confronted with a multitude f distressing clinical situations, but they reported the ost emotional distress when providing futile care,

eeling that they are “torturing” the patient by provid-

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ng aggressive care, and when dealing with difficult amilies.

I thank Mitchell Levy, MD, Susan Ross RN, and Donna aze, RN, for their administrative support of this research

nvestigation. I also thank the MICU nursing staff for haring their personal experiences and participating in he study.

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