Theory of Nursing Practice in End-of-Life Care Essay.
Aim. The aim of this study was to generate a grounded theory of nursing practice in end-of-life care.
Background. Provision of end-of-life care that meets the needs of the dying person and their family is complex. While symptom
control, disease management and psychosocial care are well understood, there is less evidence about how nurses manage
everyday practicalities in challenging organisational environments.
Design. Qualitative using Glaser’s method of grounded theory.
Methods. Data were collected from 30 semi-structured interviews with registered nurses working in end-of-life care in New Zealand. Data were analysed using constant comparative techniques. Theoretical sampling and memo writing furthered theoretical development. Theory of Nursing Practice in End-of-Life Care Essay.
Results. Nurses used the process of moderated guiding to manage different expectations in end-of-life care. Moderated guiding
included checking out, involving and supporting. Guiding was both controlling and non-controlling. Moderation was required,
as there were tensions in nursing practice because of patient control issues, resource constraints and the individual nurse’s
emotional investment in the nurse–patient relationship. Theory of Nursing Practice in End-of-Life Care Essay.
Conclusions. Moderated guiding raises questions about the challenges nurses face in a health care environment where
responsibilities for care have changed.
Relevance to clinical practice. Moderated guiding explains the role nurses have as resource managers in health services where
wider social and economic issues impact multiple clinical demands and influence nursing practice.
Key words: end-of-life care, grounded theory, nurse–patient relationships, nurses, nursing
Accepted for publication: 16 August 2010
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Introduction
End-of-life care is terminal care. It includes the palliative
management of patients in the last part of their life ‘when it is
clear that a person is in a progressive state of decline’ (Watson
et al. 2005, p. xxv). The World Health Organisation (2009)
states that palliative care aims at providing quality care for
the patient and family at the end-of-life. Quality care includes
the identification of physical, psychosocial and spiritual
problems and the prevention and relief of suffering. Nurses
are communication intermediaries in care delivery, as they
move between the patient and family and service team (Thompson et al. 2006, Calvin et al. 2007).Understanding
the patient’s values and needs, and integrating family dynamics with inter-sectorial agency requirements and palliative care
options, is challenging (Oliver et al. 2005). When the uncertainty of anticipating when and how a death will occur is
considered, it is evident that the nursing role is challenging. Theory of Nursing Practice in End-of-Life Care Essay.
Many nurses see their role as facilitating a ‘good death’
(Beckstrand et al. 2006, p. 38). Because understandings of a
‘good death’ vary (Steinhauser et al. 2000, Randall & Downie
2006), nurses tend to focus on managing a respectful death
Author: Antoinette M McCallin, MA, BA, PhD, RN, Associate
Professor, Faculty of Health and Environmental Sciences, AUT
University, Auckland, New Zealand
Correspondence: Antoinette M McCallin, Associate Professor,
Faculty of Health and Environmental Sciences, AUT University, 90
Akoranga Drive, Northcote 0627, Private Bag 92006, Auckland
1142, New Zealand. Telephone: +64 9 9219999 ext. 7884. Theory of Nursing Practice in End-of-Life Care Essay.
E-mail: Antoinette.mccallin@aut.ac.nz
2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 2325–2333 2325
doi: 10.1111/j.1365-2702.2010.03543.x
(Wasserman 2008). Nursing management includes taking into
account the needs of family caregivers and relatives (Hudson
2003, Andershed 2006), interdisciplinary teamwork (Oliver
et al. 2006) and collaborative relationships (Waldrop 2006).
Patient and family experiences are documented (Andershed
2006, Spichiger 2008, Fisher & Colyer 2009, Funk et al. 2009).Theory of Nursing Practice in End-of-Life Care Essay. There is less evidence about how nurses manage
everyday practicalities in end-of-life care situations. This
paper presents findings from a grounded theory study about
end-of-life care in New Zealand. Grounded theory is useful,
as it identifies the practical realities of a situation and
explains how the everyday problems of practice are managed.
Better understanding of end-of-life care has the potential to
explain how nurses manage sensitive situations where patient
and family expectations are very different. Theory of Nursing Practice in End-of-Life Care Essay.
The study
Aim
The aim of this study was to generate a grounded theory of
nursing practice in end-of-life care.
Research design
Glaser’s method of grounded theory informed research design
(Glaser 1998, 2001, 2003). In grounded theory because
participants identify concerns in an area, literature is not
reviewed formally prior to a study. Background literature
was scanned to obtain a sense of existing knowledge and
research potential. Scanning suggested that nursing practice
in end-of-life care was challenging. What exactly was the
research problem? This situation was ideal for grounded
theory research where participants identify their main con-
cern and discuss how they manage that. Grounded theory is
useful because it helps explain what is actually happening in
practical life, rather than describing what should be going on.
The research question was: ‘What is the main concern of
nurses working in end-of-life care and how do they manage
that?’ Constant comparative analysis, open, substantive and
selective coding, memo writing, theoretical sampling and the
identification of a core process are all hallmarks of grounded
theory (Glaser & Strauss 1967) and shaped research design.
The aim was to generate a theoretical explanation of what
was happening in nursing practice at the end of life.
Ethical considerations
The research was approved by the University Ethics Com-
mittee. Participants were recruited using professional net-
works. Clinical educators were asked to identify expert
nurses in end-of-life care. The educator approached a nurse
to check interest in being a research participant. If interest
was confirmed, email addresses were passed on and the
researcher contacted the potential participant directly. Infor-
mation explaining the research, participation involvement,
confidentiality and privacy issues was sent out either
electronically or by mail. A week later, I followed through
with a phone call to confirm or not interest in participation.
Six participants were identified in this way. At the end of their
interview, they were asked whether they knew of other nurses
who might be interested in talking with the researcher.
Names were passed on and I contacted potential participants
by email, attaching an information pack about the study.
Email contact was helpful, as the recipient could choose to
respond or not. Those who responded were telephoned. This
provided an opportunity for them to ask questions and, if all
was well, to set up an interview time. All participants were
fully informed prior to interview.
Participants
Thirty participants were recruited for the study. Nineteen of
the 30 nurses had postgraduate qualifications, including two
with nursing doctorates; seven were masters qualified; and 10
had either a postgraduate diploma or certificate in nursing.
Of the remaining 11, four were degree-educated and seven
had been trained in hospital programmes; 29 participants
were women. There was one man. Ages ranged from 40–
60 years. Participants had a minimum of 20 years experience
as registered nurses. End-of-life care experiences varied from
10–33 years. Experienced nurses were chosen, as Glaser
(1978) believes experts in an area are knowledgeable about
the general problem area and the inclusion of such people
maximises the possibilities for data collection. There were
five main practice settings including two hospices, an aged
care facility, an acute paediatric hospital and an acute care
hospital.
Data collection and analysis
Data were collected from interview and analysed concur-
rently using constant comparative techniques. All partici-
pants were interviewed once; four were interviewed twice.
Interviews lasted about an hour. The first interviews were
with experienced nurses who worked in hospices and aged
care facilities. Initial questions were broad. Participants were
asked to talk about nursing practice in end-of-life care.
Concepts were identified after the first interview and formed
the basis of questions for subsequent interviews. Coding was
AM McCallin
2326 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 2325–2333
open. Towards the end of the interview, the researcher asked
each participant about their main concern in end-of-life care
and how they managed that. The core process, guiding, was
identified after fifteen interviews and formed the basis for
theoretical sampling.
During theoretical sampling, questioning focused on guid-
ing. Coding was selective. Participants still raised new ideas,
for example negotiating and conversational manoeuvring,
which were discussed in relation to guiding. For instance, the
paediatric nurses suggested that conversational manoeuvring
was important in guiding. Did meaning change depending on
the service? Was conversational manoeuvring common in all
end-of-life care situations or did it occur only when nurses
were working with children and their families? Theoretical
sampling provided an opportunity for the researcher to talk
with participants who could answer these questions. Inter-
viewing concluded when the same ideas were repeated and
data were saturated. Throughout this process, constant
comparative analysis continued. A complete re-analysis of
the data suggested that the core process was moderated
guiding. During analysis, every effort was made to move
description to conceptualisation (Glaser 2001, 2003). Memo
writing, which is important for conceptualisation, assisted the
researcher to think through the relationships in the emerging
theory.
The rigour of the theory will be judged by others,
depending on fit, workability, relevance and modifiability
(Glaser & Strauss 1967). Readers will confirm the fit if the
findings resonate with nurses working in end-of-life care. The
theory will be workable if the theory of moderated guiding
and the excerpts presented are seen as relevant to practising
nurses. Because grounded theory knowledge is expected to be
transferable to different settings, this research should reso-
nate with nurses practising in other locations. A grounded
theory is always open to modification according to the
changing social conditions.
Results
The main concern for nurses in end-of-life care was that
patients, families and nurses had different expectations of
how end-of-life care might be managed. The nurses had a
professional preference that the patient and/or family would
control what happened at the end of life. This was not always
possible because often expectations were idealistic and the
patient and/or family had no idea of what to expect. Nurses
managed expectation difference using a process of moderated
guiding:
People are autonomous beings. It’s about who has the power or
control. This model suggests that ideally each of us needs space to be
autonomous, to control what we have to do …. When I am working
with patients, ultimately I would like them to have total control, but
it has to be moderated according to what is possible, what they are
ready for and what they can do at this moment. Many people have
had a lifetime of being controlled by others and if you say, ‘You
decide how you want to manage your dying’, I don’t think they have
the faintest idea of how to be autonomous and it would be cruel to
expect it. So you have to moderate [guiding] according to what they
can do. (Interview # 25)
There were three sub-processes in moderated guiding:
checking out, involving and supporting. Checking out
involved informational understanding and potential alterna-
tives. Involving encompassed conversational manoeuvring
and negotiating choices, while supporting consisted of
deliberating and safeguarding (Table 1).
Checking out
When a patient was admitted to end-of-life care, nurses
checked out informational understanding and explored
potential alternatives for care. Patient situations varied, so
nurses were careful not to make assumptions about what
Table 1 Overview of the components of the core process of moderated guiding
Sub-processes Categories Indicators of categories
Checking out Informational understanding Information gaps, entitlements, service access, legal requirements, misunderstandings
and information provision
Potential alternatives Discussion about options and places for care, family inclusion, family circumstances
and community support
Involving Conversational manoeuvring Patient advocacy, questioning, careful messaging, informed consent, family inclusion
and looking at the whole
Negotiating choices Professional relationship, patient rights and autonomy, family agenda and managing
resource constraints
Supporting Deliberating Professional judgement, professional boundaries, sorting out family dynamics, problem
solving and encouraging participation
Safeguarding Connecting, holding uncertainty, facilitating, cultural sensitivity, backing off and
creating space
Research for nursing practice Moderated guiding
2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 2325–2333 2327
might happen. Checking out the situation clarified family
arrangements. Some patients had no family whatsoever;
others had blended families with complex needs; an increas-
ing number had older partners who were unable to care for a
loved one at home; while a few did not want any family
involvement at all. Furthermore, while patients had received
information about options for care, the sensitivity of the
situation compromised listening and limited understanding.
When these challenges occurred in a health context where
there had been substantial change to service delivery, nurses
took on a role as guidance moderators. Nurses guided
patients so that they had a clearer understanding of expec-
tation possibilities:
There are quite different expectations between the staff and the
patients and families. Whether it is hospice or community, patients
and families are unrealistic. They think everything is free and it’s not.
People are demanding; they are distressed. They don’t hear everything
you say. We give out a lot of information. … we can only lay out the
facts, clarify and answer questions and allow people to think and come
to a decision about the options and alternatives. (Interview # 13)
Informational understanding
Informational understanding referred to patient’s under-
standing of resources and requirements. Indicators for
informational understanding were information gaps, entitle-
ments, service access and legal requirements, misunder-
standings and information provision. Some patients were well
informed, others poorly informed. Lack of information con-
tributed to idealistic expectations that could not always be
realised in the services offered. Before expectations could be
moderated, nurses had to find out what was understood:
People do not know what they are entitled to. District nurses and
home help are available. Most patients and families don’t have
information and may not access those services. Even if they have
some information, it usually is not enough, or it’s inaccurate … there
are misunderstandings about what they think will happen and what
they are entitled to. Patients and families find out that what they
expect and what is available is different. (Interview # 4)
Part of the problem with information sharing was because of
the patient and family readiness to receive unwelcome
information. Some patients were responsive to receiving
information, if a nurse took time to sit down and explain
what was happening. Once information was understood, it
was easier to discuss potential alternatives for care.
Potential alternatives
Potential alternatives were defined as the checking out of care
placements. The indicators were discussion about options
and places for care, family inclusion, family circumstances
and community support. In New Zealand, some people die in
acute care hospitals but, depending on the bed state at the
time, access to acute care cannot be assumed. Although
everyone is entitled to have respite care in a hospice for 7–
10 days at the end of life, the small number of hospice beds
limits access. If extra care is required, a patient can transfer to
a private sector aged care facility, as long as the patient and
family can afford to pay for private care. The alternative is
home care with district nursing and home help services pro-
vided. The expectation that families would be responsible for
home care was unrealistic for some, as families were not al-
ways available and sometimes caregivers were very old.
Finding alternative placements was not straightforward:
The problem with community care is that the resources are simply
not there. Hospice acts as a gap – if you can get a bed. In the
community there are not enough carers and there is a lack of
resources to look after patients at home. Hospitals discharge patients
with no support. Families cannot provide the care as they are
working and have to look after their own families. (Interview # 8)
Although family input into end-of-life care was challenging,
nurses understood that the acute care bed state was such that
the majority of patients would be sent home to die. This made
it imperative to involve families in end-of-life care.
Involving
In involving nurses were guidance moderators in that they
were communication intermediaries between the patient and
whoever else could be involved in patient care. Nurses had a
role as patient advocates, acting on behalf of their patients,
trying to secure family involvement for a time when the
patient might need help and assistance. As indicated, only a
few would receive hospital or hospice care and many would
end their lives at home. Because community resources were so
limited, nurses had to involve families in discussions about
future care, in the hope that they would be available to look
after their relative. When family expectations exceeded
possibilities nurses took control, using conversational
manoeuvring and negotiating choices to keep the family
involved:
I send messages to patients and their families. I drop facts into the
conversation … we are a short stay facility in hospice. We have
dilemmas with the number of beds we have. If patients don’t die fast
enough we meet to discuss where else they can go … It is about
expectations. We look at the whole family and the patient and we
discuss and negotiate a path of care. The patient chooses what they
want. (Interview # 16)
AM McCallin
2328 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 2325–2333
Conversational manoeuvring
Conversational manoeuvring referred to the have-to-have
conversations nurses had with the patient and family. Fami-
lies did not always hear what was said, or had trouble pro-
cessing unpleasant information, so conversations had to be
arranged to make sure everyone knew what was going on.
The indicators for this category were patient advocacy,
questioning, careful messaging, informed consent, family
inclusion and looking at the whole. Initially, conversations
began with the patient:
I am guided by where the patient is at. Do they want me to inform,
involve or explain to the family? If they are reluctant I question that
and steer the conversation to clarify what is wanted or not. It’s their
life, not mine. Some people want families involved and others don’t. I
clarify what the patient wants. (Interview # 23)
While the patient was the focus of care, nurses had a
professional obligation to make sure the next of kin and/or
family were informed. Family involvement varied. Convers-
ing with a family struggling with impending loss was not
easy. Some families were composed, while others did not
cope well at all. If families did not want to discuss difficult
topics like resuscitation, nurses became directive in their
communication. They took control, manoeuvring conversa-
tions, making sure everyone was fully informed:
Some families really want active treatment until the end. You know
it’s not appropriate – you try guided conversations about withdrawal
of treatment – they are the have to haves, especially about CPR. You
have to be very clear and make sure the relatives know you won’t be
doing the dramatics at that point. (Interview # 28)
Negotiating choices
In negotiating choices, nurses identified the patient and/or
family agenda of how they hoped the end of life might occur.
End-of-life care in any organisation is constrained to some
extent, and families seldom have complete freedom of choice.
Nurses developed a professional relationship with the family,
using their knowledge and experience to draw attention to
different choices. The indicators of this category were pro-
fessional relationship, patient rights and autonomy, family
agenda and managing resource constraints.
Nurses were respectful of the patient right to choose.
Nurses expected the patient and family to take some control
of the situation, as best they could, while the nurse walked
beside them. The nurse participants were very clear that they
were not there to tell people what to do. They did recognise
however that patient and family expectations were sometimes
beyond organisational resources. Thus, different family
expectations were controlled using the process of negotiating.
If expectations could not be realised, nurses used their
professional experience to offer choices in a way that
encouraged families to find other options:
Often we can give them choices. We say, ‘Look! This is what we
think. What do you think?’ So it’s a together approach – not an
individual one. If I can see there might be another way I will bring
that up as a choice. There are things that have to be done and ways
we can give choices. We are constantly negotiating … there isn’t a
right or wrong way; it’s about what would be best in this situation.
(Interview # 18)
Supporting
As life came to an end, nurses were pulled in many directions,
individualising care and managing organisational issues that
impacted nursing practice. The professional nursing role
required that the nurse protect vulnerable people in highly
emotional situations, all the while remaining professional,
sometimes therapeutic. Ensuring a patient had a good death
was challenging in practice, if a patient did not think they
were dying, or when a family did not need or want the
supports professionals associated with a good death. Nonetheless, nurses drew on their professional skills to find ways of supporting the patient and family using the processes of
deliberating and safeguarding:
Guidance is about supporting and also ensuring that the family are aware of what is happening. It’s being with them, not saying what is right or wrong, having some empathy…. It’s trying to minimise the suffering and protecting them. You can’t totally protect people but you can keep them safe. … What people want is somebody to be supportive, sympathetic and professional. They don’t want you to take over their grief but to be competent and objective. (Interview # 22)
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Deliberating
As has been seen, nursing practice in end-of-life care was
complex and included responsibility for the patient, to the
family and to the organisation. The indicators for deliberating were professional judgement, professional boundaries,
sorting out family dynamics, problem solving and encouraging participation. Professional judgement was invaluable to manage complicated responsibilities and consider what could be achieved:
This raises ethical questions …Trying to work out what is professional and what’s not, what you have to do and don’t have to do. Theory of Nursing Practice in End-of-Life Care Essay.
What are you actually willing to take a risk on and say, ‘Where is my professional part?’ Is it to completely support the family and how they want to do things, or is it having to consider you are a part of Research for nursing practice Moderated guiding
2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 2325–2333 2329
a ward and an organisation? It’s using professional judgement.
(Interview # 19)
There was a certain level of professional detachment in
deliberating that was self-protective for the nurses them-
selves. Nurses were sensitive to family situations, although
they noted that family expectations sometimes changed over
time, which meant that professional input was adjusted
accordingly. Families sought guidance, although they readily
rejected professional suggestions if they did not fit with
family expectations. In some instances, supporting was
deliberately firm but gentle: Theory of Nursing Practice in End-of-Life Care Essay.
Families need help and support and this is affected by family
dynamics. Who’s causing trouble? I find that out and acknowledge
the difficulties. Families need to retain control of the situation. The
nursing work is more guiding than controlling … I remind [the family]
that they are not onlookers at the death but active participants and
push them forward, enabling them – I am in the background on the
fringe of the relationship – there if they need me. (Interview # 10)
Safeguarding
Safeguarding occurred when nurses noticed that what was
happening was less than ideal and needed to be improved, if
the patient was not to suffer. The indicators of safeguarding
were connecting, holding uncertainty, facilitating, cultural
sensitivity, backing off and creating space. During safe-
guarding, support was family focused: Theory of Nursing Practice in End-of-Life Care Essay.
I’m keeping the situation safe for them while they go through the
process in the way they need to. No one family does it the same way.
It’s almost about holding some uncertainty for them. Holding them
safe … allowing them to go where they need to go. I facilitate some
safeness about that experience. (Interview # 31)
Ocassionally nurses were required to facilitate a process that
had particular meaning for the family. Nursing support
included cultural sensitivity: Theory of Nursing Practice in End-of-Life Care Essay.
Families and friends reclaim the person if that is what they want to
do. Some people and cultures don’t. It’s backing right off my wanting
to sort things out and facilitating people in whatever way you can to
let them do what they want to do. … you have to connect much more
with the family. You are still connected to the patient but it is more
about sharing with the family. (Interview # 17)
Nurses had to be careful as well that they did not move into
deeper-level connections typical of the rescuing role. Thus,
safeguarding had a dual purpose of keeping the situation safe
for the patient and family and ensuring that the nurse was
protected. Backing off distanced nurses and created space for
families who needed time with their relative at this significant
time. Theory of Nursing Practice in End-of-Life Care Essay.
Discussion
The research results demonstrate how nurses manage different expectations for care in a context where nursing practice is moderated by broader social and economic issues that impact professional practice. Guiding helps nurses move the patient and family through end-of-life care. Guiding is both controlling and non-controlling. Control is seen in the nurses’ reference to checking out, manoeuvring, negotiating and deliberating. The non-controlling element of guiding includes
involving, supporting, facilitating and encouraging. Guiding
also requires moderation, as there are limits to what nurses
can do for patients in a health environment where there are
changing responsibilities for care. Results suggest that the
patient and family do not always understand that they are
active participants in care who share responsibility for care
with health professionals. The emphasis on patients as
autonomous people, self-experts who are capable of choosing
from the options and taking control of what will happen to
them, suggests that control and resource constraints also
affect a nurse’s emotional investment in the nurse–patient
relationship. Theory of Nursing Practice in End-of-Life Care Essay.
Research results show that nurses believe that control is
patient and/or family directed. The patient’s right to choose is
central to patient control. Nurses encourage patients to
choose what they want to happen and where. This causes
some tension as patient preferences may not always be
realised. Nurses respond by focusing on the protective
element in control, whereby they act on the patient’s behalf
and push the family forward to become involved in care.
Nurses moderate sensitive situations, helping the family
understand that the decreased length of stay in public
organisations means that the patient will be discharged to
the community. Family expectations are variable however. Theory of Nursing Practice in End-of-Life Care Essay.
Few understand that they are required to take control of end-
of-life arrangements for their relative, either at home or in an
aged care facility. Lowton (2009) argues that the place of care
is significant and most people want to die at home. This is
more difficult today, because of the increasing number of
women in the workforce and the concurrent reduction in
community family support (Rummery 2009). As a result,
nurses have a central role involving families and working
through different expectations. Theory of Nursing Practice in End-of-Life Care Essay.
Expectations for control are complex. Some patients have
high perceptions of control, whereas others have low
perceptions of control (Kidd et al. 2009). This perhaps
accounts for some of the control issues evident in moderated
guiding. Patient control is intertwined with choice. Appar-
ently, patient control over choice activates responsibility
(Kielmann et al. 2010) and improves quality of life (Gurland
AM McCallin
2330 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 2325–2333 & Gurland 2009), although this may be dubious if quality of life is time-limited. Patient control over choice is not
necessarily open-ended in a financially constrained environment where everyone who needs care obtains some access to
services, even if it is restricted. In particular, length of stay is
time-constrained; therefore, nurses guide the patient and
family through situations that are controlled organisationally. Indeed, Giblin (2002) argues that the organisational
environment has the power to support or exert controls over practice at the end of life. Workplace pressures, time
restrictions and the constant call for organisational efficiency potentially limit professional control and the ability to engage in socio-emotional encounters with patients.
Control and resource issues also impact the professional relationship nurses have with the patient and family. The
research findings suggest that there is value in therapeutic relationships and being with patients, albeit in moderation.
There is moral responsibility inherent in the nurse–patient
relationship, although this is moderated by individual nurses.
In this study, it was evident that some nurses move beyond
what Naef (2006) calls the efficiency-effectiveness rhetoric to
engage in meaningful ‘being with’ relationships that recognise
the patient as a human being. This is quite different to the
more traditional ‘doing for’ nurse–patient relationship that
focuses on tasks and technical competency. In contrast, some
nurse participants report a connecting relationship, a more
distant professional relationship that is possibly grounded in
humanistic ideals. Theory of Nursing Practice in End-of-Life Care Essay.
It is clear that the most experienced nurses connect with the
patient and family from the margins of the nurse–patient
relationship. They are willing to offer professional advice, to
empathise with people, but limit emotional investment
according to individual energy. Cash (2007) questions the
expression and sustainability of compassion over time,
drawing attention to the compassion fatigue that occurs
when structures and resources are limited. This fits with
another explanation that lies in the wider socio-political
structures that constrain nursing practice and perhaps
account for a form of discursive empathy (Sinclair & Monk
2005). Theory of Nursing Practice in End-of-Life Care Essay.Thus, the nurse–patient connection is modified
according to socio-cultural issues that affect resources and
relationships. The end result is that nursing practice is
moderated by other events that are happening to larger
numbers of patients and families in the clinical context.
At the same time, guiding and the willingness to engage
emotionally with patients at a deeper level are moderated by
individual energy. Depending on the number of patients
requiring care and the intensity of the nursing input required,
it is not surprising that often the most experienced nurse
reserves the right to limit therapeutic encounters if they do
not have the emotional energy for that work. Clearly,
moderated guiding provides some boundaries to the nurse–
patient relationship and fosters self-preservation for nurses.
The introduction of objectivity and distance into the professional nursing relationship helps nurses prevent their own suffering (Lavoie et al. 2008). Theory of Nursing Practice in End-of-Life Care Essay.
Limitations
This theory provides some explanation of nursing practice in
end-of-life care in New Zealand. The study is limited, as it is
context specific. The majority of nurses practised in acute
care, hospice, or aged care facilities and most of their patients
were those dying of cancer.Theory of Nursing Practice in End-of-Life Care Essay. The research findings may not be
applicable to end-of-life care nursing in the community or
nursing patients who have chronic conditions such as heart
failure or asthma. Research findings may be limited because
nurses typically spoke about patients who had families to
look after them. Nursing those that do not might present a
different perspective altogether. Explanation is, therefore,
general. The potential transferability of findings into different
contexts, with completely different people, could be investigated in future research. Theory of Nursing Practice in End-of-Life Care Essay.
Conclusion
Moderated guiding explains how very experienced nurses
manage different expectations in end-of-life care, ensuring
that patients and families retain control of this sensitive life
process. Guiding is both controlling and non-controlling. Theory of Nursing Practice in End-of-Life Care Essay.
Guiding is moderated, as nursing practice is more limited
when patients have control and choice over what will
happen, how and where. While the patient and family do
not always understand the implications of their active
participation in care, nurses use the process of moderated
guiding to check out, involve and support the patient and
family in a context where nursing practice is affected by
social and economic constraints and the individual nurse’s
emotional investment in the nurse–patient relationship. The
theory of moderated guiding offers some explanation of how
nurses manage the practical problems of practice in end-of-
life care. Theory of Nursing Practice in End-of-Life Care Essay.
ORDER A CUSTOM-WRITTEN, PLAGIARISM-FREE PAPER HERE
Relevance to clinical practice
The practicalities of nurses adjusting their expectations and
managing wide-ranging family expectations for care in an
environment that emphasises resource management are
complex. While nurses are well practised at managing
resources that relate directly to patient care, they may be
Research for nursing practice Moderated guiding
2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 2325–2333 2331
less comfortable working through expectations that are
related to broader social and economic resources, which are
seen to be an organisational or government responsibility. Theory of Nursing Practice in End-of-Life Care Essay.
Resource management however is now the domain of all
health professionals, who are expected to do more with less
and provide quality care that meets the expectations of
patients and families, and fits in with organisational requirements. While the nurses in this study were highly experienced, those who have less experience may find such situations challenging. Although experienced nurses have become experts at continuing to strive to provide the very
best of care for the patient and family, less experienced nurses
may need some assistance as they find new ways of balancing
patient and family expectations with professional ideals and organisational demands. Nurses may require staff development within their organisations to help them identify new
strategies for nursing practice in the resource-strapped
environment. Theory of Nursing Practice in End-of-Life Care Essay.
Acknowledgements
The author thanks the participants who gave their time
willingly.
Contributions
Study design: AM; data collection and analysis: AM and
manuscript preparation: AM.
Conflict of interests
None. Theory of Nursing Practice in End-of-Life Care Essay.
Ethical approval
Ethical approval was granted by the AUT University Ethics
Committee in January 2005, reference number 05/04.
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