Iranian nurses’ preparation for loss: finding a balance in end-of-life care

CULTURAL DIVERSITY IN NURSING PRACTICE

Iranian nurses’ preparation for loss: finding a balance in end-of-life care

Ali Zargham Boroujeni, Rakhshandeh Mohammadi, Sayede Fatemeh Haghdoost Oskouie and

Jonas Sandberg

Aim. To explore the nurse–patient interaction in terminally ill situations in acute care, focusing on the nurses’ preparation for

loss.

Background. Caring for dying patients can be a distressing and sometimes even threatening experience for nurses. Despite the

vast body of literature on nurse/patient interaction and the quality of end-of-life care, few studies focus specifically on nurses’

experience.

Design. A grounded theory approach was used to explore nurses’ interaction with dying patients and their families and examine

how nurses deal with situations in which the patient’s death is inevitable.

Method. Eighteen nurses were interviewed up to three times each at three teaching hospitals in Isfahan, Iran, during autumn

2006. A shortlist of possible participants was obtained by means of theoretical sampling and those who had experienced the

death of patients and were able to express their feelings verbally were selected.

Results. The results clarified a core consideration: striking a balance between restorative and palliative care, information and

hope, expectations and abilities and intimacy and distance.

Conclusion. Attaining a balance in caring for dying patients is a major challenge to nurses: it concerns not only their interactions

with patients and their families, but also their perceptions of themselves and their actions in end-of-life care.

Relevance to clinical practice. In end-of-life care, it is important for nurses to be able to change the focus of their care when the

patient’s condition is diagnosed as irreversible. They also need to be well equipped to maintain a balance, thereby preparing

themselves for the patient’s forthcoming death.

Key words: death and dying, grounded theory, nurses, nursing, nurse–patient relationship, palliative care

Accepted for publication: 11 March 2008

Introduction

The nurse/patient relationship is viewed as fundamental to

nursing practice (Benner & Wrubel 1989, Ramos 1992,

Tanner 1995, Weissman & Appleton 1995, Taylor 1998,

Rajnikanth 2006). Nurse/patient interactions encompass

wide-ranging attitudes and behaviour in the interpersonal

and clinical domains of nursing practice. It is the main way of

promoting quality in nursing care (Cossette et al. 2005). May

(1995) highlighted nurses’ key role in helping terminally ill

patients come to terms with their imminent death. Such work

is highly demanding and often stressful: the nurse/patient

relationship goes beyond listening and talking, with the

patient being the object of clinical attention or a subject

Authors: Ali Zargham Boroujeni, BSc Nursing, MSc Nursing, PhD,

Faculty of Nursing and Midwifery, Isfahan University of Medical

Science and Health Services, Isfahan, Iran; Rakhshandeh

Mohammadi, BSc Nursing, MSc Nursing, PhD, Associate Professor,

Faculty of Nursing and Midwifery, Iran University of Medical

Science and Health Services, Tehran, Iran; Sayede Fatemeh

Haghdoost Oskouie, BSc Nursing, MSc Nursing, PhD, Associate

Professor, Faculty of Nursing and Midwifery, Iran University of

Medical Science and Health Services, Tehran, Iran; Jonas Sandberg,

RN, PhD, Senior Lecturer, Department of Caring and Public Health

Sciences, Malardalen University, Eskilstuna, Sweden

Correspondence: Ali Zargham Boroujeni, BSc Nursing, MSc Nursing,

PhD, Faculty of Nursing and Midwifery, Isfahan University of

Medical Science and Health Services, Hezarjerib St., Isfahan 81744,

Iran. Telephone: +98 913 310 8979.

E-mail: [email protected], [email protected]

� 2008 The Authors. Journal compilation � 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 2329–2336 2329

doi: 10.1111/j.1365-2702.2008.02437.x

manifesting psychosocial problems. Here, not only do

patients wish to speak, but they are also intimately known

to their nurses, who express sympathetic concern while

patients reveal the most private aspects of their lives (Mok &

Chiu 2004).

Given their incurability and imminent death, caring for

dying patients can be an emotionally painful and sometimes

threatening experience (Mok et al. 2002). Studies have shown

more stress related to death and dying among nurses in

intensive and hospice care than elsewhere. They experience

both grief and moral distress when a patient’s death is

inevitable (Davies & Oberle 1990, Rashotte et al. 1997, Yam

et al. 2001). This high level of work-related stress contributes

to burnout, feelings of anxiety and inadequacy, self-doubt,

low self-esteem, irritability, depression and ill health. The

resulting absenteeism, low morale and rapid turnover among

staff compromise the quality of care provided to patients and

their families (Yam et al. 2001).

Despite the vast body of the literature on nurse/patient

interaction, as mentioned by Mok and Chiu (2004), we found

few studies (Wong & Lee 2000, Yam et al. 2001, Wilkin &

Slevin 2004) on how nurses cope with the death and suffering

of dying patients. Moreover, none of these studies were

conducted in Islamic countries. Our study therefore focuses

on the following questions about Iranian nurses:

• How do they interact with dying patients and their

families?

• How do they cope with the inevitability of the patients’

death?

During the process of dying, time is limited and the patient

is vulnerable. The nurse/patient relationship is therefore an

interesting area of investigation (Mok & Chiu 2004). This

study therefore aimed to explore and elucidate nurse/patient

interaction in end-of-life situations, while focusing on the

nurses’ preparation for loss.

Cultural context is highly relevant to the focus of this

study. Attachment among Iranian family members is very

strong: the whole family often becomes involved in problems

related to the patient. Nurses frequently meet, communicate

with and even get to know almost all of a patient’s family

members, especially when the patient’s hospital stay is

prolonged. Since in Persian culture all human beings are seen

as essentially united, reducing other people’s pain and

suffering is perceived as a significant role in society.

Another cultural aspect of nursing in Iran is that in Islam,

the country’s main religion, caring for the sick and needy

enjoys particular respect. Allameh Tabatabaei, a famous

20th-century Islamic philosopher, compares one night of

providing care to 70 years of prayer. Although nursing

education in Iran is based on western nursing knowledge, the

nurse/patient relationship is highly influenced by the above-

mentioned sociocultural context.

Methods

Methodology

Qualitative methodology was deemed the most appropriate

to fulfil the study aim. Grounded theory (Glaser & Strauss

1967) was selected as a research method to gain a better

understanding of nurses’ feelings and action in nurse/

patient interaction. This understanding will help to enhance

nursing practice as suggested by Speziale and Carpenter

(2003). Grounded theory, a qualitative research method

used for examining existing social processes in human

interaction, originated in the symbolic interpretive school

of interaction (Speziale & Carpenter 2003). Grounded

theory is a general method aimed at either generating new

theory from data or elaborating on and modifying exist-

ing theory in the light of new data (Strauss & Corbin

1998).

Study context

This study was conducted in three teaching hospitals, in three

settings: two of acute care and one of cancer care. Iranian

teaching hospitals are referral centres and a significant

proportion of inpatients have no financial and/or insurance

support.

Ethics approval

The study was approved by the Research Ethics Committee

of the Faculty of Nursing at the Iran University of Medical

Sciences. Informed consent was obtained, confidentiality

preserved and the participants’ right to withdraw from the

study at any time ensured. The researchers were available to

the participants by telephone and email at any time.

Participants

Eighteen participants were selected by purposeful and theo-

retical sampling (Strauss & Corbin 1998). We chose individ-

uals with at least one experience of a patient’s death, who

could express their feelings verbally. The participants were

nurses working in Isfahan, Iran. These nurses were engaged

in the care of high-risk patients in, for example, intensive care

units (ICUs), coronary care units (CCUs), paediatric surgical

wards and cancer care centres, where mortality was high.

Each participant had at least a first university degree and a

A Zargham B et al.

2330 � 2008 The Authors. Journal compilation � 2008 Blackwell Publishing Ltd, Journal of Clinical Nursing, 18, 2329–2336

year’s nursing experience and was willing to take part in

the study.

Data collection

Semi-structured interviews (Polit & Hungler 1995) were used

for data collection. Interviews are the main method of data

collection in grounded theory (Strauss & Corbin 1998). We

posed general questions, such as ‘What is your experience

concerning the provision of care for terminally ill patients?’

and ‘What is the meaning of death and how do you feel about

it?’ Probing questions were then used to encourage the

respondents to describe their feelings in detail.

All interviews were conducted, recorded and transcribed in

Farsi by AZ and approved by the participants. Each interview

was analysed immediately as suggested by Strauss and Corbin

(1998) before doing next interview. As analysis proceeds, the

questions that arose by making comparisons among incidents

became the guides for further data gathering. This provided

opportunities for theoretical sampling based on the emerging

concepts. Themes from earlier interviews were identified and

explored further in subsequent ones.

Achieving conformability of the data involved several

strategies. This study was the main researcher’s (AZ) first

research experience of using the grounded theory method.

RM, FO and JS, being experienced in using this method,

supervised every step of this study. Once the interviews had

been conducted and accurately transcribed by the main

researcher (AZ), the other researchers double-checked the

transcripts. A second interview was then conducted with each

participant to check all the codes with her and to ensure

uniform researcher understanding of the meaning of state-

ments. On four occasions, a third interview was conducted.

Questions then focused on the participants’ ideas as

expressed in the previous sessions, to achieve a better

understanding of their ideas and greater depth in the

interviews and analysis. So, the final data set consisted of

40 interviews. The interviews were partially translated into

English by AZ for use in this paper.

Data analysis

Data analysis was based on the model recommended by

Strauss and Corbin (1998) and described by Speziale and

Carpenter (2003). We used only a word-processing software

to type transcribed interviews, marking the text during open

coding and print out the documents. During the phase of

open coding, the researchers read all the interviews thor-

oughly several times and coded selected incidents, facts, key

words or phrases in the text. In this phase, nearly 1000

primary codes were extracted. The codes and data were then

compared, similarities and differences noted and categories

and subcategories defined. Through a further process of

comparison and theoretical sampling, the researchers deter-

mined each category’s properties and dimensions. This

resulted in 13 conceptual categories. With axial coding at

the end of the selective coding phase, the core variable was

identified. At this stage, a core variable of ‘finding a balance’

emerged clearly from all the data examined. Open and axial

codes were reviewed by all the main researcher’s colleagues

(see Table 1 for the analytical process).

Results

Participants described their experience of patients’ death as a

major impact on their lives as well as on their careers.

Analysis revealed that nurses felt closer to long-stay than

short-stay patients and experienced more emotional pain

after their death. However, further analysis showed a

paradox: deaths of patients with prolonged hospitalisation

were often better tolerated by nurses than sudden deaths.

‘Length of stay’ was therefore identified as important not

only in providing context for enduring interactions, but also

of its connection with the length of time available for nurses

Table 1 Example of analysis process

Story Open coding Axial coding

Patient’s death had greater impact on me before when I was younger and less

experienced, I became more intimate with patients and … their problems had more

effect on me. Now … because of my experiences, for things that I’ve learned that I

shouldn’t get so closed to my patients, I become less affected and it (patient’s death)

is less painful for me

Impact of patient’s death

Younger/less experienced

Intimacy

Patient’s problems

Patient’s emotions

Experience

Learned not become too close

Distance

Less affected

Less pain

Intimacy/distance

Cultural diversity in nursing practice Nurses’ preparation for loss


to prepare for losing the patient. ‘Preparation for loss’ was

identified as a highly influential part of the nurses’ interac-

tions with their patients. This phase started when the nurse

realised that the patient was going to die.

The core theme of ‘finding a balance’ identified as central

to all categories, thus covers establishing a rapport and

preparing for loss. From the participants’ accounts, four

dimensions of balance were identified:

• between restorative and palliative care;

• between information and hope;

• between expectations and abilities;

• between intimacy and distance.

Below, the various aspects of striking a balance, as

expressed by the respondents, are explained.

Balance between restorative and palliative care

To deal with the forthcoming death of the patient, nurses

must find a balance between restorative and palliative care.

This is understood as a process: according to the nurses, their

main responsibility was ‘care to cure’ the patients and save

their lives. The nurses expressed this by such statements as:

‘We’re responsible for our patients’ lives’ or ‘I do my best, even

putting myself at risk …to save my patient’s life’.

At the same time, they were concerned about their patients’

pain and discomfort. Participants pinpointed their role as

nurses in reducing the patients’ pain and suffering. They felt

happy when they succeeded in bringing about recovery. One

respondent said:

When CPRs [cardiac pulmonary resuscitations] are successful, you

feel deeply satisfied. … This satisfaction, knowing that you yourself

can be effective and enable the patient to recover, gives you

happiness.

The other main point made by these nurses concerned long-

stay patients who may experience prolonged suffering. They

may also impose tremendous financial and emotional

pressure on the patients’ families. Long-term interaction

brings nurses closer to their patients and the patients’

families. The nurses experience a sense of inadequacy

regarding these patients, when no cure was possible. They

do their best but attain poor results and can do nothing to

assist recovery. Respondents described the feeling of being

‘on a wild-goose chase’: it was, they felt, their duty and

wish to help, but their efforts yielded no clear benefit. A

challenge might then arise. The nurses had to change their

main endeavour from restorative to palliative care, which

placed heavy pressure on them since it involved anticipating

the patients’ death. The nurses’ well-established, long-

standing interaction and resulting intimacy with the patients

and their families made the prospect of patients dying

unpleasant:

It is hard to accept that your patient is dying when you feel close to

her, because of the depth of your relationship.

Nurses experienced mixed feelings about patients dying. New

nurses grieved more, crying and succumbing to feelings of

sadness for days when patients they knew well died. They

described their feelings about their interactions with such

patients in emotional terms, with compassion and empathy

towards the patients and their families. Experienced nurses,

on the other hand, described it more professionally, reporting

that after a patient’s death it was a solace to know they had

done their best and helped to alleviate the patient’s and

family members’ pain and suffering. These nurses also

realised the importance of conserving their energy to help

other patients. They were better able to recognise the dying

process in their patients and were more responsive to signs of

exhaustion in patients and family members. They would

embark on ‘unofficial’ personal quests to gather information

about dying patients. This information enabled them to

prepare themselves and find solace when the patients died.

One nurse with 14 years’ experience in paediatric surgery

described a patient with a long history of hospitalisation due

to multiple illnesses and complications since the age of three

or four. The child’s ill-health was compounded by the

parents’ inability to cope and their severe financial problems.

Eventually, the nurse said:

I told her doctor to do something. He said she would probably die

after the operation and I said it would be better for her to be freed

from the pain. Everyone was exhausted … so the family consented

and… she died some days after the operation, in the ICU. Several

years later I bumped into the mother in a park. She told me that after

the child’s death, the situation improved for the family. She had never

wanted the girl to die, but her death was a deliverance both to them

and to herself.

Sometimes, nurses were unable to maintain a balance. This

happened when they lacked sufficient experience to change

their caring approach in time, or when the patient’s death

occurred suddenly. The nurse might then experience pro-

found, painful grief after the patient’s death:

I can’t accept it when some patients die. I get stressed out and can’t

stop thinking about it even when I get home. I feel sad when the death

is sudden and can’t accept it. I’m confused for a while, too. It’s such a

pity…

By switching their focus from restorative to palliative care

in-time as they anticipate the patients’ death, nurses have

A Zargham B et al.


time to prepare themselves and ensure that appropriate end-

of-life care is given.

Balance between information and hope

Maintaining a balance between information and hope

involves two processes. One is a matter of how nurses can

inform patients and their families without impairing the

patient’s will to live. The other is an internal process of

development in the nurses.

The nurses reported what they believed was common

sense: that informing dying patients of their incurable

condition may provoke despair and a deterioration in their

health. In caring for the patients, the nurses were therefore

anxious to preserve a balance between information and

hope. Since patients present in a ward during a patient’s

cardiac arrest notice the unavoidable disturbance of a CPR,

such incidents (irrespective of the success or failure of the

CPR) provide major occasions for nurse/patient interactions

to take place. Respondents stated that patients often show

their concern by asking what happened to the patients

involved and whether they are still alive. The nurses must

then explain what has happened and try to reassure the

patients, who may express a wish to know about their own

situation and whether their own lives will end shortly. In

such situations, the nurses stated, they need to choose their

words carefully if they are to convey enough information to

patients without reducing their hope to live. They realised

that this is a very difficult and sometimes almost impossible,

task.

Finding the right balance between information and hope in

meeting patients’ families was seen as another daunting task.

According to the nurses, family members try to keep patients’

hopes up and ask the nurses to do the same, by not informing

the patients about their forthcoming death. Nurses sometimes

attempt to avoid providing information by waiting for the

doctor to do so and referring patients’ and their families’

questions about the prognosis to their physician. However,

the nurses said that patients usually guess that they are dying:

There was a cancer patient we didn’t tell about his disease. In the end,

he found out by seeing his laboratory test results. Then, when he

understood what was happening, the destructive process of his

disease began.

One nurse said she sometimes felt an obligation to tell the

truth. On a few occasions she had done so but the family had

later objected, believing it had destroyed the patient’s hope

and made his or her health worse.

The nurses concluded that a failure to strike a balance

between information and hope may provoke aggressive

behaviour, when the patient’s family assume that the nurse

is responsible for the patient’s death.

Finding an inner balance between information and hope

was related to the nurses’ beliefs in God. Their dominant

belief, which they attributed to their religious background,

was that a cure is God-given and health professionals are

God’s tools, who restore patients to health by using modern

medical and nursing care. However, they added that this is

not God’s only way of curing patients: there is always hope

that God will give health directly back to patients. Nurses

prayed for their patients and/or saw patients’ family members

praying for them:

Sometimes, for example, a person with a powerful faith has better

tolerance. I myself often pray, cry a little and strive to gain some kind

of balance.

Balance between expectations and abilities

In the nurses’ view, achieving a balance between patients’

and/or their families expectations of nurses and the nurses’

own abilities is very important. Nurses suggested that, if they

were unable to attain this balance, their pain after a patient’s

death would be intense:

After my patient’s death, when I told his family about it, they became

very angry and blamed me. I think they were wrong. They counted

too much on my abilities. It makes you feel bad if you could have

saved a patient’s life but didn’t succeed. That distresses me very

much. Sometimes I’ve even needed medication to get back to normal.

Nurses perceived an imbalance between the expectations of

patients’ families and their own ability. Some families, they

said, expect their ill member to recover completely after a

hospital stay and therefore blame the nurses if the patient gets

worse. Their anger and aggressive behaviour may make the

nurse feel she has acted inappropriately. But when nurses

were able to meet the family’s expectations, or the family

did not expect the patient’s full recovery, the nurses felt

competent:

Family visits to patients were banned in the CCU and if a patient

became very ill the family members got angry. They couldn’t really

understand what was going on and had no idea about our efforts. So

the most difficult task for me was when I had to tell the family that

the patient was dying.

Some nurses even feared physical violence after telling the

families:

When death is sudden, I prefer to ask a man to tell the family. I’m

afraid of being beaten, maybe because I don’t know exactly how one

is supposed to tell them.



One of the nurses suggested that making appointments for

family members to visit terminally ill patients in the CCU

might be a way of maintaining a balance and warding off the

feeling of inappropriateness:

When I know a patient is going to die in the near future, I ask the

family to come and visit. I let them see their ill member in a critical

condition. That way, they can remember him in his final moments

and know we’ve done our best. They can see our sadness that no one

can do anything to save his life. Then they accept the patient’s death

better … and sometimes they even come and thank us, the nurses,

after the patient dies.

The other aspect of finding a balance between expectations

and abilities was, according to the nurses, their multiple

responsibilities. Nurses reported on the pressure they expe-

rienced when multitasking to meet the expectations of

various people, such as their own families, the patients and

their families, managers and colleagues:

I try to do my best, especially when there’s a very ill patient in the

ward. I was really diligent – running around and fetching equipment,

calling the physician, preparing medications, doing CPRs and so on. I

had to do night shifts because I was looking after my baby in the

daytime. And patients’ conditions worsen suddenly more often at

night. They get bradycardia and need pacemakers, become com-

pletely AV-blocked or overdose on digitalis. It’s a difficult time to

work, but there were no awards, no extra payments, nothing from

managers for the extra work involved. There are so many different

responsibilities and expectations all around you, with no resources…

The nurses also reported that they were subject to the

expectations of other members of the healthcare team. They

needed support and acceptance from colleagues, especially at

times of sadness due to a patient’s death, to accomplish their

tasks properly:

When you’re sad, it helps if they are gentle and don’t keep telling you

‘Do this’ or ‘Do that’ but tell each other instead ‘Don’t disturb her –

she’s feeling miserable.

The analysis appears to show that empathy from colleagues

may play a key role in helping nurses to strike a balance. The

nurses usually tried to find this balance to protect themselves

from a sense of guilt about the patient’s death.

Balance between intimacy and distance

Preserving a balance between intimacy and distance is most

relevant to the nurses’ own feelings and actions concerning

preparation for death. They stated that, when they were

caring for critically ill patients, they perceived the patients’

pain. They also became familiar with the patients and their

families and aware of the patients’ and families’ problems,

hopes, concerns and feelings by communicating with them.

Often, a bond was established between them and, as we have

seen, the patient’s death, especially when it came suddenly

and unexpectedly, affected the nurses greatly.

The nurses expressed various feelings: sadness, awkward-

ness, weariness, turmoil, distress and a fear of proximity to

death for themselves. Sometimes they feared falling ill with

the patient’s disease. Some also expressed their feelings in

physical manifestations and behavioural changes, such as

insomnia, loss of appetite, loss of motivation to work, crying

and anxiety. The more interdependent the nurse and the

patient and/or the patient’s family had been, the greater the

impact of the patient’s death on the nurse. This was described

by relatively inexperienced nurses in particular:

I worked for a month or two in a leukaemia ward at the beginning of

my career. I remember patients who came there for chemotherapy:

we became friends and… even formed emotional bonds. So, I cried

with the patients’ families and even went to patients’ funerals. We

became close, there was a kind of affection – that was the reason.

More experienced nurses stated that they protect themselves

from this kind of feeling by keeping a professional distance

between themselves and the patients and not becoming too

familiar with them. Evidently, long-term interactions be-

tween nurses on the one hand and patients and their families

on the other bring about a sense of intimacy and attachment

that tends to exacerbate nurses’ grief and sense of bereave-

ment when patients die. After a few years’ work experience,

nurses therefore reach the conclusion that restricting their

communication with the patients and their families means

that they will be less affected if the patient dies. On the other

hand, the nurses stated that they were unable to detach

themselves entirely from their patients because communica-

tion is an important part of nursing. Experienced nurses thus

choose to strike a balance, communicating as much as they

feel necessary but keeping a certain distance, to protect

themselves from pain if the patient dies:

When I was younger and less experienced, I got closer to my patients

and their death then had a greater impact on me. But now, because of

my experience, I’ve learnt that I mustn’t get so involved. That makes

me less affectionate and less wretched if the patient dies.

Discussion

Achieving balance in the care of dying patients is perceived as

a major challenge to nurses. It relates not only to nurse/

patient interaction, but also to nurses’ feelings about them-

selves and their actions when caring for dying patients.

A Zargham B et al.


To date, most research efforts have concentrated on

patients’ needs, feelings and satisfaction with end-of-life care

(Heyland et al. 2003, 2006, Mayfield Arnold et al. 2006,

Quintana et al. 2006), with relatively little acknowledgement

of nurses’ feelings about and attitudes towards this kind of

care. This study illuminated how nurses prepare themselves

for loss of their patients. The findings showed that nurses

faced various challenges in dealing with the feelings of

ambivalence that arise from maintaining a balance between

two extremes. One aspect of this balance was the balance

between restorative and palliative care. On the one hand,

nurses want to save the patients’ lives; on the other, they want

to reduce the patients’ pain and suffering and promote a

peaceful death. Yam et al. (2001) reported that switching

from curative to palliative care is experienced by nurses as

stressful. In contrast, our findings show that, although this

switch is a major challenge to nurses, they report less grief

and distress due to patients’ deaths when they have made this

change in time to ensure that they have provided the

appropriate care for the patients.

Another challenge to nurses is to keep the patients hopeful

while informing them about their forthcoming death and the

dying process. Under Islamic law, God is the creator of life

(Sarhill et al. 2001), who controls life and death. With this

belief, there is always a way back to health and life through

God. Hope is therefore an important component in end-of-

life care. This is consistent with Feudtner (2005), who

concluded that hope is a powerful influence in our lives and is

everywhere, even in and around a person who is dying. The

nurses in this study generally believed that informing patients

of the likelihood of their death would erode their hope. In a

few cases, they also feared a backlash from the patient’s

family. Although the findings of Heyland et al. (2006), from

the patient’s point of view, showed that more than 90%

agreed with the provision of information about their disease,

our own study’s findings appear to show that these Iranian

nurses disagree with Heyland’s respondents. This difference

may be because of their different cultural contexts.

Nurses must realise, according to Periyakoil et al. (2005),

that grieving patients’ hope shifts but is not lost. Thus,

patients may shift from a hope for cure to a hope for

prolongation of life to a hope for dying well. However, no

such studies concerning patients’ attitudes in this matter have

been carried out in Iran.

The participants in this study also experienced pressure

from excessive expectations. Nurses face challenges finding a

balance between their abilities and the expectations of

patients and their families, colleagues and managers.

Krichbaum et al. (2007) reported that up to 40% of a

nurse’s working day is taken up by meeting the

ever-increasing demands placed on them by the system of

healthcare delivery. However, it is especially interesting to

note that in this research, the nurses also experienced

pressure in meeting the expectations of their own family

members. This may be a suitable area for further exploration

in culture-oriented research.

A phenomenological study examining the meaning of care

among nurses in intensive care revealed that when a nurse did

identify with a patient, emotional involvement was apparent.

She would describe the situation as ‘being close to’ the patient

(Beeby 2000). Nurses in our study also stated that ‘getting

close to’ their patients is inevitable, because communication

is the greater part of nursing care. They therefore faced a

major challenge: to strike the right balance between intimacy

and distance, so as to protect themselves from the impact of

the patient’s death.

Conclusion

Throughout this study, the nurses displayed concern for the

patients they were caring for. As a result, there was a sense of

closeness and intimacy between the nurses and their patients.

Our findings of this study showed that although feelings of

intimacy appear common among nurses, especially the

younger and less experienced ones, they do not consider

these feelings to be entirely acceptable. The respondents

reported that when they become too close to their patients,

they were more affected by the patient’s death. As a result,

the nurses tended to keep some distance from their patients.

This helped them not only to protect themselves from the

pain of severe grief after the patient’s death, but also to be

ready to help other patients with professionalism at all times.

Iranian nurses appear to need training in giving appropri-

ate information to their patients and the patients’ families,

when the patient’s death is approaching. Nurses should

realise that informing the patient does not necessarily push

them into hopelessness. There is also a need for advanced

communication skills among nurses to allow them to better

manage communication between physicians, patients and

their families without keeping the families out of CCU which

may contribute to their anxiety and consequent anger.

Relevance to clinical practice

To give families the right support, at the right time, nurses

need to understand their own feelings. We therefore recom-

mend giving nurses in end-of-life care constant support and

encouragement to express their feelings. If nurses are to

support dying patients and their families, they must them-

selves receive support. To meet the needs of terminal patients



and their families, nurses must possess the tools for striking a

balance in various ways. This balance enables them to cope

with their own emotions when patients die. Further exam-

ination of this matter is required.

Contributions

Study design: AZ, RM, FO; data collection and analysis: AZ,

RM, FO, JS and manuscript preparation: AZ, JS.

References

Beeby JP (2000) Intensive care nurses’ experiences of caring. Part 2:

Research findings. Intensive Critical Care Nursing 16, 151–163.

Benner PE & Wrubel J(1989) The Primacy of Caring : Stress and

Coping in Health and Illness. Addison-Wesley, Menlo Park, CA.

Cossette S, Cara C, Ricard N & Pepin J (2005) Assessing nurse–

patient interactions from a caring perspective: report of the

development and preliminary psychometric testing of the Caring

Nurse–Patient Interactions Scale. International Journal of Nursing

Studies 42, 673–686.

Davies B & Oberle K (1990) Dimensions of the supportive role of the

nurse in palliative care. Oncology Nursing Forum 17, 87–94.

Feudtner C (2005) Hope and the prospects of healing at the end of

life. Journal of Alternative and Complementary Medicine 11(Sup-

pl. 1), S23–S30.

Heyland DK, Tranmer J, O’Callaghan CJ & Gafni A (2003) The

seriously ill hospitalized patient: preferred role in end-of-life deci-

sion making? Journal of Critical Care 18, 3–10.

Heyland DK, Dodek P, Rocker G, Groll D, Gafni A, Pichora D,

Shortt S, Tranmer J, Lazar N, Kutsogiannis J & Lam M (2006)

What matters most in end-of-life care: perceptions of seriously ill

patients and their family members. Canadian Medical Association

Journal 174, 627–633.

Krichbaum K, Diemert C, Jacox L, Jones A, Koenig P, Mueller C &

Disch J (2007) Complexity compression: nurses under fire. Nursing

Forum 42, 86–94.

May C (1995) ‘To call it work somehow demeans it’: the social

construction of talk in the care of terminally ill patients. Journal of

Advanced Nursing 22, 556–561.

Mayfield Arnold E, Abbott Artin K, Griffith D, Lund Person J &

Graham KG (2006) Unmet needs at the end of life: perceptions of

hospice social workers. Journal of Social Work and End of Life

Palliative Care 2, 61–83.

Mok E & Chiu PC (2004) Nurse–patient relationships in palliative

care. Journal of Advanced Nursing 48, 475–483.

Mok E, Lee WM & Wong FK (2002) The issue of death and dying:

employing problem-based learning in nursing education. Nurse

Education Today 22, 319–329.

Periyakoil VS, Kraemer HC, Noda A, Moos R, Hallenbeck J,

Webster M & Yesavage JA (2005) The development and initial

validation of the Terminally Ill Grief or Depression Scale (TIGDS).

International Journal of Methods in Psychiatric Research 14, 202–

212.

Polit DF & Hungler BP (1995) Nursing Research: Principles and

Methods. Lippincot Company, Philadelphia, PA.

Quintana JM, Gonzalez N, Bilbao A, Aizpuru F, Escobar A, Esteban

C, San-Sebastian JA, de-la-Sierra E & Thompson A (2006) Pre-

dictors of patient satisfaction with hospital health care. BMC

Health Services Research 6, 102.

Rajnikanth A (2006) Essential Communication in Nursing. Jaypee

Brothers, New Delhi.

Ramos MC (1992) The nurse–patient relationship: theme and vari-

ations. Journal of Advanced Nursing 17, 496–506.

Rashotte J, Fothergill-Bourbonnais F & Chamberlain M (1997)

Pediatric intensive care nurses and their grief experiences: a phe-

nomenological study. Heart and Lung 26, 372–386.

Sarhill N, LeGrand S, Islambouli R, Davis MP & Walsh D (2001)

The terminally ill Muslim: death and dying from the Muslim per-

spective. American Journal of Hospice Palliative Care 18, 251–

255.

Speziale HS & Carpenter DR(2003) Qualitative Research in Nursing:

Advancing the Humanistic Imperative, 3rd edn. Lippincott Wil-

liams & Wilkins, Philadelphia, PA.

Strauss AL & Corbin JM(1998) Basics of Qualitative Research:

Techniques and Procedures for Developing Grounded Theory, 2nd

edn. Sage Publications, Thousand Oaks.

Tanner CA (1995) Living in the midst of a paradigm shift. The

Journal of Nursing Education 34, 51–52.

Taylor B (1998) The nurse–patient relationship as the common

ground of nursing specialties. Australian Journal of Advanced

Nursing 15, 6–7.

Weissman J & Appleton C (1995) The therapeutic aspects of

acceptance. Perspectives on Psychiatric Care 31, 19–23.

Wilkin K & Slevin E (2004) The meaning of caring to nurses: an

investigation into the nature of caring work in an intensive care

unit. Journal of Clinical Nursing 13, 50–59.

Wong FK & Lee WM (2000) A phenomenological study of early

nursing experiences in Hong Kong. Journal of Advanced Nursing

31, 1509–1517.

Yam BM, Rossiter JC & Cheung KY (2001) Caring for dying infants:

experiences of neonatal intensive care nurses in Hong Kong.

Journal of Clinical Nursing 10, 651–659.

A Zargham B et al.


Documents

Iranian nurses’ preparation for loss: finding a balance in end-of-life care