Saving lives is the first priority in emergency departments. Nevertheless, end-of-life care (EOLC) for patients and their families is important in these departments when the patient's life cannot be saved. EOLC in emergency departments is described in guidelines and protocols for nursing practice and nursing education (Bailey, Murphy, & Porock, 2011; George et al., 2016; Grant at al., 2013; Rojas et al., 2016). However, several problems have been identified related to the provision of EOLC in emergency departments. These problems involve uncertainty of treatment, quality of life of patients, ethical problems, and relationships among medical team members (Forero et al., 2012). Related obstacles and difficulties in nursing practice have been reported in previous studies (Beckstrand, Rasmussen, Luthy, & Heaston, 2012; Beckstrand, Wood, Callister, Luthy, & Heaston, 2012; Kongsuwan et al., 2016).
Nurses' role in EOLC involves providing family care and collaborating with the rest of the medical team (Emergency Nurses Association, 2013). Thus, nurses are a very important part of EOLC. Previous work has found that nurses feel that the emergency department is an unsuitable environment for providing EOLC and a particularly difficult context in which to face death, but they reported working to provide the best EOLC possible (Hogan, Fothergill-Bourbonnais, & Brajtman, 2016).
The perceptions of nurses who provide EOLC in situations of distress are fraught with conflict (McCallum & McConigley, 2013), and conflict is a major factor affecting burnout among nurses (Lanz & Bruk-Lee, 2017). Emergency nurses have been found to have less developed coping strategies and higher death avoidance than nurses who provide palliative care (Peters et al., 2013). Therefore, examining the psychological burden among emergency nurses is important. Past studies have focused on ethical conflicts in patient care and matters of life and death (Jimenez-Herrera & Axelsson, 2015). There is no research examining the structure of the conflict that nurses experience when providing EOLC in emergency departments or the factors influencing this conflict. Therefore, the primary aims of this study were (i) to clarify the structure of the conflict that nurses experience when providing EOLC in emergency departments and (ii) to explore the factors influencing this conflict.
This was a cross-sectional study.
Definition of Terms
End of life was defined as the period from when it is determined that no positive outcome can be expected until death. EOLC was defined as care provided by nurses to patients and their families, in collaboration with the medical team, including nurses' behaviors and thoughts following the recognition that the patient is facing death. Conflict was defined as psychological burdens and difficulties in nursing practice and care decision making because of conflict with others or oneself.
Participants and Procedures
Participants were nurses working in emergency departments in Japan. We calculated the sample size using G*power (effect size = 0.25, α = .05, power = 0.95; Faul, Erdfelder, Lang, & Buchner, 2007). The inclusion criteria were nurses who currently provided EOLC to patients and their families in an emergency department. The exclusion criteria were nurses who did not directly provide this care to patients and their families—for example, nurse managers.
To identify potential participants, we used simple random sampling to select 45 general hospitals from a list of 283 hospitals that had emergency departments (Japanese Association for Acute Medicine, 2016). We contacted these 45 selected hospitals by telephone to explain the study, and 21 general hospitals agreed to participate. Self-administered survey questionnaire forms were sent to potential research participants by the nursing director at each hospital from March to May 2017.
This study was approved by the institutional review board at Osaka University (Ref. No. 16259).
The questionnaire assessed demographic data (age, gender, employment status, education, and nursing qualification), experience (years of nursing practice, years of emergency nursing practice, experience of learning about EOLC, experience with EOLC, and experience of bereavement with their own relatives), and institutional information (institutional support system for EOLC and discussions on EOLC among medical team members).
Conflict: Item Development Process
Preliminary items were prepared on the basis of semistructured interviews with nurses who provided EOLC in emergency departments (Satake & Arao, 2018). These items were developed from items used in previous studies (Beckstrand, Rasmussen, et al., 2012; Beckstrand, Wood, et al., 2012; Gagnon & Duggleby, 2014; Heaston, Beckstrand, Bond, & Palmer, 2006; Kongsuwan et al., 2016) that described experiences, obstacles, and perceptions of nurses providing EOLC in emergency departments and critical care units.
Four domains covering a total of 36 items were preliminarily adopted. The four domains were “conflict about the environment of EOLC” (seven items), “conflict about the best practice for the patient and their family” (15 items), “conflict about relationships with the family and medical team” (10 items), and “conflict about ethical problems” (four items). For each item, respondents were asked about the extent to which they experienced conflict when providing EOLC, with answers on a 6-point Likert-type scale.
Conflict: Content Validity of Items
Content validity was assessed by two researchers. We also asked five nurses with nursing experience in emergency departments or intensive care units to complete the questionnaire and report on which items were difficult to answer and which items were necessary. As a result of this process, we modified the wording of some items.
The statistical analysis was conducted in several stages. First, an exploratory factor analysis was conducted using the principal factor method with promax rotation after good–poor analysis and item–total correlation analysis. Based on the results of the factor analysis, attributes with factor loadings less than .4 (standardized regression coefficient) or no loading on any components, as well as those that cross-loaded on more than one component, were deleted. Cronbach α coefficient was calculated to investigate internal consistency. Both t tests and one-way analysis of variance were used to test for differences in the mean conflict scores by demographic characteristics, experience, and support system. Age and years of experience were found to be non-normally distributed, so we used quartile values for these variables. Multiple comparisons were made using the Tukey method (homoscedasticity) and the Games–Howell test (heteroscedasticity). All of the statistical analyses were performed using SPSS, Version 23 (IBM, Armonk, NY).
There were 524 potential participants identified, of whom 290 (55.3%) responded to the survey. After excluding questionnaires that were not fully completed, 288 (55.0%) responses were included in the analysis. Characteristics of the respondents are summarized in Table 1.
The Kaiser–Meyer–Olkin sample adequacy test value was 0.890, indicating that the matrix was suitable for factor analysis. For Bartlett's test of sphericity, p was less than .01, and the data were therefore suitable for factor analysis.
The principal factor method with promax rotation was used to test the structure of the scale. The findings indicated the presence of seven components with eigenvalues more than 1, which explained 68.70% of the variance. A scree plot analysis indicated a possible break point at the seventh component; therefore, seven components were extracted as the most suitable number of components for the subsequent analysis.
Item Selection and Naming the Factors
Items that had weak (<.40) loadings or no loadings on all components, as well as items that cross-loaded on more than one component, were deleted. The results of the factor analysis for the core components are shown in Table 2.
The components were named by applying a conceptual interpretation to each component item. The names assigned to the components were as follows: (1) conflict about ability to practice EOLC; (2) conflict about relationships with the medical team; (3) conflict about the environment for EOLC; (4) conflict about decision making; (5) conflict about family nursing; (6) conflict about patients' pain; and (7) conflict about medical limitations. The correlations between the factors were moderate, ranging from .267 to .643.
The results of the analysis for internal consistency are shown in Table 3. Each of the seven components demonstrated satisfactory internal consistency, with Cronbach α values ranging from 0.816 to 0.899.
Tests Comparing Mean Conflict Scores
The results of the analysis for tests comparing mean conflict scores are shown in Table 4. Women experienced higher levels of conflict than men on Component 7 (conflict about medical limitations). Younger nurses reported higher levels of conflict than older nurses on Component 1 (conflict about ability to practice EOLC).
Nurses who had experienced bereavement with their own relatives reported higher levels of conflict on Component 7 (conflict about medical limitations) than those who had not experienced bereavement. Neither nurses with experience providing EOLC as cancer nurses nor those with experience learning about EOLC were significantly different from other nurses in the sample.
On Component 2 (conflict about relationships with the medical team), Component 3 (conflict about the environment for EOLC), and Component 6 (conflict about patients' pain), nurses with an institutional support system experienced lower levels of conflict than nurses without a support system. Nurses who had a palliative care team to intervene experienced lower levels of conflict than those without the intervention of such a team on Component 3 (conflict about the environment for EOLC), Component 4 (conflict about decision making), and Component 6 (conflict about patients' pain). Nurses who had a certified nurse or certified nurse specialist to intervene experienced lower levels of conflict than those without this kind of intervention on Component 2 (conflict about relationships with the medical team), Component 3 (conflict about the environment for EOLC), Component 4 (conflict about decision making), and Component 6 (conflict about patients' pain).
Nurses working in institutions with discussion among medical team members on EOLC experienced lower levels of conflict on Component 2 (conflict about relationships with the medical team) and Component 6 (conflict about patients' pain) than those whose institutions did not have this kind of discussion.
The most important finding of this study was to identify the structure of conflicts related to EOLC that were experienced by nurses. Seven components were extracted. Overall, the main components that emerged in this study were similar to those found in previous studies about ethical conflicts (Falco-Pegueroles, Lluch-Canut, & Guardia-Olmos, 2013; Falco-Pegueroles, Lluch-Canut, Roldan-Merino, Goberna-Tricas, & Guardia-Olmos, 2015), which found that EOLC policy, environment for EOLC, staff members providing EOLC, patients' pain, and patients' decision making were important aspects of conflict experience.
One clinical implication of this finding relates to Component 1 (conflict about ability to practice EOLC). One of the ethical conflicts of nursing involves autonomy: Because decision making is shared with medical doctors, nurses may feel that they cannot play their required roles (Jimenez-Herrera & Axelsson, 2015). In the present study, nurses reported experiencing conflict about their own ability to provide EOLC. Although education on EOLC in emergency departments is developing (Grant et al., 2013), nurses' experiences of conflict about their abilities must be considered. Furthermore, the support system to enable nurses to cope with the psychological burden of providing care to patients and their families at the end of life is very important.
A second clinical implication of this finding relates to Component 7 (conflict about medical limitations). Nurses have reported a perception of powerlessness after being unable to save the lives of the patients or help their families even with aggressive treatment (Yokobori, Inoue, & Sasaki, 2012). In emergency departments, as was mentioned at the start of this article, the first priority is the saving of lives and emergency department nurses might have a negative image of death. It is necessary to consider culture when discussing appropriate support for conflict experienced by nurses in differing contexts.
A second important result of the present study involved the exploration of influences on nurses' experiences of conflict. The first type of factor found to be influential was nurses' individual characteristics and backgrounds. In this study, women experienced higher levels of conflict than men on Component 7 (conflict about medical limitations). In previous works, women have been found to have higher scores than men for moral distress, including conflict (O'Connell, 2015; Shoorideh, Ashktorab, Yaghmaei, & Majd, 2015). Gender differences found in this study are therefore consistent with previous studies. Experience with bereavement influenced Component 7 (conflict about medical limitations). When providing EOLC, nurses are faced with the patient's death and any memories of personal bereavement; they can manage their worry through self-care to enable them to provide care for the patient (Huang, Chen, & Chiang, 2016). There may, however, be no policies in place to help nurses manage the resulting conflict. Further study on the management of conflicts related to nurses' individual experiences of death is necessary. Younger nurses had higher scores on Component 1 (conflict about ability to practice EOLC), but experience with EOLC as a cancer nurse and experience learning about EOLC were not significant influences on the experience of conflict. Emergency nurses have less developed coping strategies than nurses who provide palliative care (Peters et al., 2013). However, nurses with experience providing palliative care might not be better placed to cope with the conflict in emergency departments because the context is so distinctive. Experience and learning are important for younger nurses, but characteristics of emergency departments should be added to training efforts.
A second type of factor influencing nurses' experience of conflict is the support system of the institution where they work. Nurses who had a support system, discussions about EOLC among medical team members, interventions by a palliative care team, or interventions by a certified nurse or certified nurse specialist experienced lower levels of conflict than nurses without these types of support. A support system is important, but nurses who take a main role in providing EOLC also experience conflict related to communication (Wittenberg, Goldsmith, & Neiman, 2015). Cooperation with staff members in specialized fields is necessary in the provision of EOLC in emergency departments, and communication methods should also be considered.
This study had several limitations. First, the response rate was 55%, and there could be response bias because the nature of conflict experienced by nurses who did not complete the questionnaire is unknown. Second, an assessment of test–retest reliability is needed to examine the stability of the scale used in this study. Third, investigating concurrent validity is difficult, and it is necessary to examine construct validity. Finally, having a generous and faithful character influences the management of conflict (Erdenk & Altuntas, 2017), but we did not examine these individual characteristics. Nonetheless, we believe that this study provides a unique and valuable perspective. Providing EOLC in emergency departments presents certain obstacles, so the experience of conflict by nurses directly providing EOLC to patients and their families is important.
Conflict experienced by nurses providing EOLC in emergency departments consists of seven components covering 31 items: (1) conflict about ability to practice EOLC; (2) conflict about relationships with the medical team; (3) conflict about the environment for EOLC; (4) conflict about decision making; (5) conflict about family nursing; (6) conflict about patients' pain; and (7) conflict about medical limitations. Nurses' individual backgrounds and institutional support systems were found to influence their experience of conflict. To support nurses providing EOLC in emergency departments, we should understand their experiences of conflict, including how their backgrounds influence these experiences, and construct systems that incorporate support from the specialized field of EOLC.
The authors are grateful to all of the participants. This study was supported by Grant-in Aid for Young Scientists No. 16K20766.
Bailey C., Murphy R., Porock D. (2011). Professional tears: Developing emotional intelligence around death and dying in emergency work. Journal of Clinical Nursing, 20, 3364–3372.
Beckstrand R. L., Rasmussen R. J., Luthy K. E., Heaston S. (2012). Emergency nurses' perception of department design as an obstacle to providing end-of-life care
. Journal of Emergency Nursing, 38(5), 27–32.
Beckstrand R. L., Wood R. D., Callister L. C., Luthy K. E., Heaston S. (2012). Emergency nurses' suggestions for improving end-of-life care
obstacles. Journal of Emergency Nursing, 38(5), e7–e14.
Erdenk N., Altuntas S. (2017). Do personality traits of nurses have an effect on conflict
management strategies? Journal of Nursing Management, 25, 366–374.
Falco-Pegueroles A., Lluch-Canut T., Guardia-Olmos J. (2013). Development process and initial validation of the Ethical Conflict
in Nursing Questionnaire–Critical Care Version. BMC Medical Ethics, 14(22), 1–8.
Falco-Pegueroles A., Lluch-Canut T., Roldan-Merino J., Goberna-Tricas J., Guardia-Olmos J. (2015). Ethical conflict
in critical care nursing: Correlation between exposure and types. Nursing Ethics, 22(5), 594–607.
Faul F., Erdfelder E., Lang A. G., Buchner A. (2007). G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods, 39, 175–191.
Forero R., McDonnell G., Gallego B., McCarthy S., Mohsin M., Shanley C., Hillman K. (2012). A Literature review on care at the end-of-life in the emergency department
. Emergency Medicine International, 2012, 486516. doi: 10.1155/2012/486516.
Gagnon G., Duggleby W. (2014). The provision of end-of-life care
by medical-surgical nurses working in acute care: A literature review. Palliative and Supportive Care, 12, 393–408.
George N. R., Kryworuchko J., Hunold K. M., Ouchi K., Berman A., Wright R., Platts-Mills T. F. (2016). Shared decision making to support the provision of palliative and end-of-life care
in the emergency department
: A consensus statement and research agenda. Academic Emergency Medicine, 23(12), 1394–1402.
Grant M., Wiencek C., Virani R., Uman G., Munevar C., Malloy P., Ferrell B. (2013). End-of-life care
education in acute and critical care. American Association of Critical-Care Nurses, 24(2), 121–129.
Heaston S., Beckstrand R., Bond E., Palmer S. P. (2006). Emergency nurses' perceptions of obstacles and supportive behaviors in end-of-life care
. Journal of Emergency Nursing, 32(6), 477–485.
Hogan K. A., Fothergill-Bourbonnais F., Brajtman S. (2016). When someone dies in the emergency department
: Perspectives of emergency nurses. Journal of Emergency Nursing, 42(3), 207–212.
Huang C. C., Chen J. Y., Chiang H. H. (2016). The transformation process in nurses caring for dying patients. The Journal of Nursing Research, 24(2), 109–117.
Jimenez-Herrera M. F., Axelsson C. (2015). Some ethical conflicts in emergency care. Nursing Ethics, 22(5), 548–560.
Kongsuwan W., Matchim Y., Nilmanat K., Locsin R. C., Tanioka T., Yasuhara Y. (2016). Lived experience of caring for dying patients in emergency room. International Nursing Review, 63(1), 132–138.
Lanz J. J., Bruk-Lee V. (2017). Resilience as a moderator of the indirect effects of conflict
and workload on job outcomes among nurses. Journal of Advanced Nursing, 73(12), 2973–2986.
McCallum A., McConigley R. (2013). Nurses' perceptions of caring for dying patients in an open critical care unit: A descriptive exploratory study. International Journal of Palliative Nursing, 19(1), 25–30.
O'Connell C. B. (2015). Gender and the experience of moral distress in critical care nurses. Nursing Ethics, 22(1), 32–42.
Peters L., Cant R., Payne S., O'Connor M., McDermott F., Hood H., Shimoinaba K. (2013). Emergency and palliative care nurses' levels of anxiety about death and coping with death: A questionnaire survey. Australasian Emergency Nursing Journal, 16(4), 152–159.
Rojas E., Schultz R., Linsalata H. H., Sumberg D., Christensen M., Robinson C., Rosenberg M. (2016). Implementation of a life-sustaining management and alternative protocol for actively dying patients in the emergency department
. Journal of Emergency Nursing, 42(3), 201–206.
Satake Y., Arao H. (2018). Conflicts of nurses who provide terminal care in the emergency department
. Palliative Care Research, 13(2), 201–208.
Shoorideh F. A., Ashktorab T., Yaghmaei F., Majd H. A. (2015). Relationship between ICU nurses' moral distress with burnout and anticipated turnover. Nursing Ethics, 22(1), 64–76.
Wittenberg E., Goldsmith J., Neiman T. (2015). Nurse-perceived communication challenges and roles on interprofessional care teams. Journal of Hospice & Palliative Nursing, 17(3), 257–262.
Yokobori J., Inoue T., Sasaki Y. (2012). Experience of patients' families and recognition among healthcare providers who make decisions for withholding life-sustaining treatments in the emergent critical care unit. Journal of Japanese Association for Emergency Nursing, 14(1), 10–20.