Rural Emergency Nurses' End-of-Life Care Obstacle Experiences: Stories from the Last Frontier.

Rural emergency nurses face unique obstacles to providing quality end-of-life (EOL) care. Stories provided by emergency nurses embody their most difficult EOL care obstacles. A questionnaire was sent to 53 rural hospitals. Respondents were asked to share stories that epitomized the obstacles faced while providing EOL care in the rural emergency setting. The lack of an ideal death (eg, the nurse personally knows the patient, issues with family members, and unknown patient wishes) was the top obstacle. Other reported obstacles were insufficient ED staff and power struggles between nurses and physicians. Rural emergency nurses often provide EOL care to friends and family members, whereas their urban counterparts are likely to transfer care to nurses with no relation to the dying patient. Not only does caring for patients whom the nurse knows or is related to cause great distress to rural emergency nurses, but this unfortunately common situation also may prevent patients from receiving the highest quality EOL care.

Beckstrand RL ，Rohwer J ，Luthy KE ，Macintosh JL ，Rasmussen RJ ... -  《-》

The last frontier: rural emergency nurses' perceptions of end-of-life care obstacles.

Caring for dying patients is part of working in a rural emergency department. Rural emergency nurses are prepared to provide life-saving treatments but find there are barriers or obstacles to providing end-of-life (EOL) care. This study was completed to discover the size, frequency, and magnitude of obstacles in providing EOL care in rural emergency departments as perceived by rural emergency nurses. A 57-item questionnaire was sent to 52 rural hospitals in Idaho, Wyoming, Utah, Nevada, and Alaska. Respondents were asked to rate items on size and frequency of perceived obstacles to providing EOL care in rural emergency departments. Results were compared with results from 2 previous emergency nurses' studies to determine if rural nurses had different obstacles to providing EOL care. The top 3 perceived obstacles by rural emergency nurses were: (1) family and friends who continually call the nurse for an update on the patient's condition rather than calling the designated family member; (2) knowing the patient or family members personally; and (3) the poor design of emergency departments that does not allow for privacy of dying patients or grieving family members. The results of this study differed from the other 2 previous studies of emergency nurses' perceptions of EOL care. Nurses in rural emergency settings often work in an environment without many support personnel. Answering numerous phone calls removes the nurse from the bedside of the dying patient and is seen as a large and frequent obstacle. Personally knowing either the patient or members of the family is a common obstacle to providing EOL care in rural communities. Rural nurses often describe their patients as family members or friends. Caring for a dying friend or family member can be intensely rewarding but also can be very distressing. Rural emergency nurses live and work on the frontier. Little EOL research has been conducted using the perceptions of rural emergency nurses possibly because of the difficulty in accurately accessing this special population of nurses. Rural emergency nurses report experiencing both similar and different obstacles compared with their counterparts working in predominately non-rural emergency departments. By understanding the obstacles faced by emergency nurses in the rural setting, changes can be implemented to help decrease the largest obstacles to EOL care, which will improve care of the dying patient in rural emergency departments. Further research is needed in the area of rural emergency nursing and in EOL care for rural patients.

Beckstrand RL ，Giles VC ，Luthy KE ，Callister LC ，Heaston S ... -  《-》

Rural Emergency Nurses' Suggestions for Improving End-of-Life Care.

Many patient visits to emergency departments result in the patient dying or being pronounced dead on arrival. The numbers of deaths in emergency departments are likely to increase as a significant portion of the U.S. population ages. Consequently, emergency nurses face many obstacles to providing quality end-of-life (EOL) care when death occurs. The purpose of this study was to identify suggestions that emergency nurses have to improve EOL care, specifically in rural emergency departments. A 57-item questionnaire was sent to 53 rural hospitals in 4 states in the Intermountain West, plus Alaska. One item asked nurses to identify the one aspect of EOL care they would change for dying patients in rural emergency departments. Each qualitative response was individually reviewed by a research team and then coded into a theme. Four major themes and three minor themes were identified. The major themes were providing greater privacy during EOL care for patients and family members, increasing availability of support services, additional staffing, and improved staff and community education. Providing adequate privacy for patients and family members was a major obstacle to providing EOL care in the emergency department, largely because of poor department design, especially in rural emergency departments where space is limited. Lack of support services and adequate staffing were also obstacles to providing quality EOL care in rural emergency departments. Consequently, rural nurses are commonly pulled away from EOL care to perform ancillary duties because additional support personnel are lacking. Providing EOL care in rural emergency departments is a challenging task given the limited staffing and resources, and thus it is imperative that nurses' suggestions for improvement of EOL care be acknowledged. Because of the current lack of research in rural EOL care, additional research is needed.

Beckstrand RL ，Smith KE ，Luthy KEB ，Macintosh JLB ... -  《-》

Emergency nurses' perception of department design as an obstacle to providing end-of-life care.

Of the 119.2 million visits to the emergency department in 2006, it was estimated that about 249,000 visits resulted in the patient dying or being pronounced dead on arrival. In 2 national studies of emergency nurses' perceptions of end-of-life (EOL) care, ED design was identified as a large and frequent obstacle to providing EOL care. The purpose of this study was to determine the impact of ED design on EOL care as perceived by emergency nurses and to determine how much input emergency nurses have on the design of their emergency department. A 25-item questionnaire regarding ED design as it affects EOL care was sent to a national, geographically dispersed, random sample of 500 members of ENA. Inclusion criteria were nurses who could read English, worked in an emergency department, and had cared for at least one patient at the EOL. Descriptive statistics were calculated for the Likert-type and demographic items. Open-ended questions were analyzed using content analysis. Two mailings yielded 198 usable responses. Nurses did not report that ED design was as large an obstacle to EOL care as previous studies had suggested. Nurses reported that the ED design helped EOL care at a greater rate than it obstructed EOL care. Nurses also believed they had little input into unit design or layout changes. The most common request for design change was private places for family members to grieve. Thirteen nurses also responded with an optional drawing of suggested ED designs. Overall, nurses reported some dissatisfaction with ED design and believed they had little to no input in unit design improvement. Improvements to EOL care might be achieved if ED design suggestions from emergency nurses were considered by committees that oversee remodeling and construction of emergency departments. Further research is needed to determine the impact of ED design on EOL care in the emergency department.

Beckstrand RL ，Rasmussen RJ ，Luthy KE ，Heaston S ... -  《-》

Emergency nurses' suggestions for improving end-of-life care obstacles.

More than 123 million ED visits are reported annually. Many patients who arrive for care to help extend their lives instead die while in the emergency department. Emergency departments were designed to save lives rather than to provide optimal end-of-life (EOL) care. Emergency nurses care for these dying patients and their families. The purpose of this study was to determine what suggestions emergency nurses have for improving EOL care. Emergency nurses were asked which aspects of EOL care they would like to see changed to improve how patients die in emergency departments. Of the 1000 nurses surveyed, 230 provided a total of 295 suggestions for improving EOL care. Content analysis was used to identify categories of qualitative responses. Responses were coded individually by research team members and then compared with ED EOL literature. Clusters of data were formulated to form themes with sufficient data returned to reach saturation. Five major themes and four minor themes were identified. The major themes were increasing the amount of time ED nurses have to care for dying patients, allowing family presence during resuscitation, providing comfortable patient rooms, providing privacy, and providing family grief rooms. Large numbers of patients seek care in emergency departments. Emergency nurses are often called on to care for dying patients and their families in this highly technical environment, which was designed to save lives. Emergency nurses witness the obstacles surrounding EOL care in emergency departments, and their recommendations for improving EOL care should be implemented when possible.

Beckstrand RL ，Wood RD ，Callister LC ，Luthy KE ，Heaston S ... -  《-》