Article Review

A descriptive study of coping strategies used by Medical Intensive Care Unit nurses during transitions from cure- to comfort-oriented care James M. Badger, PhD, APRN, BC, Providence, Rhode Island OBJECTIVE:The aim of this study was to describe Medical Intensive Care Unit (MICU) nurses’ coping behaviors while caring for a patient whose medical treatment transitioned from cure- to comfort- oriented care.

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

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

CONCLUSIONS:MICU nurses are dynamic and resourceful when responding to challenging end-of- life patient care situations.(Heart Lung® 2005;34:63-8.) P roviding end-of-life care to patients in the Medical Intensive Care Unit (MICU) often re- quires dramatic shifts in attitudes and thera- peutic interventions. This is especially true as inten- sive care unit (ICU) staff transition from extending life to allowing life to end. Nurses are routinely involved in social negotiations about maintaining or withdrawing life-support treatment. Implement- ing this type of change in therapeutic goals may occur as a single, complete change in direction or may occur with time as specific life-support treat- ments are gradually discontinued. 1 Providing nursing care to patients dying in the MICU requires a conscious move from the “rescue” mode to approaches that recognize death’s inevita-bility and subsequent refocusing efforts on provid- ing comfort-care. There is, however, a paucity of knowledge regarding how MICU practitioners expe- rience this turning point or exploring the more per- sonal dimensions of ICU nursing, specifically, the psychological sequaele of MICU staff members as they impacted are during the transition from pro- viding life-saving care to providing life-ending care.

The use of a descriptive qualitative research design with brief selective participant observation and fo- cus group interviews was used to explore the coping experiences of MICU nurses. REVIEW OF THE LITERATURE Coping behavior can be defined as the innate, naturally occurring personal response by an individ- ual confronted with a stressful situation. 2Maloney and Bartz 3explored the personality and coping characteristics of ICU versus non-ICU staff. ICU nurses were found to be more adventurous, felt less powerful, and were viewed as more “detached” than non-ICU nurses. Chapman 4found that nurses who From the Departments of Nursing and Psychiatry, Rhode Island Hospital, Providence, Rhode Island.

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

doi:10.1016/j.hrtlng.2004.08.005 ISSUES IN ADMINISTRATION HEART & LUNG VOL. 34, NO. 1 www.heartandlung.org 63 had consistent access to social support systems experienced less frustration and stress associated with providing care in the ICU setting. Adaptive coping techniques commonly included defensive behaviors such as cheerful denial, non-sense busi- nesslike manners (isolation), passive withdrawal, humor, and— occasionally—angry outbursts.

There were, however, constraints placed on the expression of anger by the situation and the group at large. 5Staff members learn to suppress or repress overt hostility. Habituation is both inevitable and necessary if critical care nurses are to adapt to the ICU environment. According to Hay and Oken, 5 “staff must maintain an underlying alertness to dis- cern and respond to cues which may have special meaning” (p. 111). Other adaptive coping behaviors included talking things out, active mastery of com- plex technical procedures, and drawing on mutually shared past experiences. 6Maladaptive coping be- haviors were exemplified by emotional withdrawal and avoiding the patient, fostering overdependence, acting out (calling out sick, coming in late, or not completing assignments), focusing on equipment or technical aspects of care, projection, denying or repressing all feelings, or excessive treatment such as too frequent monitoring.

7 Staff members commonly develop behaviors to maintain a professional demeanor during their inter- actions with dying patients and bereaved family mem- bers. It is not uncommon for nurses to physically and/or emotionally distance themselves once it has become clear that the patient is going to die. Conboy- Hill 8attributed this distancing behavior as related to both a lack of preparation for death and to self-pro- tection. Irritation and frustration are common reac- tions among staff members who lose a patient. Mis- management of these emotions can set up defensive barriers to the vulnerability and sadness individuals feel but wish to avoid. 9Siegel 10 summed the matter up by saying, “dealing with people, as opposed to caring for people, leads to depersonalization and pain for everyone” (p. 659). Failure to define a personal role in caring for the dying patient and his or her family may make it difficult for nurses to truly become in- volved or perhaps derive personal satisfaction from their experience. 11 Davies et al. 12 reported that nurses experience grief distress when they realize the inevitability of a patient’s death but must continue with the realities of an active treatment regimen. Providing palliative care in the acute care setting may seem contrary to their normal curative focus and cause role strain.

Interpersonal distress may result from inconsisten- cies related to beliefs, values, opinions, knowledge,or actions that are incongruent. Additionally, the nurses’ personal values, knowledge, and behaviors may be in direct opposition to those of colleagues or in conflict with the interests of other people.

Kirchhoff and Beckstrand 13 reported that “nurses do not acknowledge having difficulty providing care to dying patients aside from conflicts that arise be- cause of families and physicians” (p. 96).

The hour-by-hour patient care responsibilities com- monly fall directly on the nursing staff. There is a constant demand on the nurse’s productivity and ef- fectiveness. Additionally, dying patients may create feelings of inadequacy for nurses. This may happen when the nurse’s perceived inadequacy conflicts with his or her idealized role of being a professional who can deal effectively with any injury or disease. Nurses may focus on emphasizing problems associated with dying patients as a means to displace these uncom- fortable feelings of inadequacy. 14 Lipp 15 believed that “qualities that give [ICU nurses] great emotional strength at working with the acutely ill tend also to make them intolerant of patients with weak spirit.” Specifically, “intensive care unit nurses are often least effective with long- stay or patients with chronic problems” (p. 41). Per- ceptual change, however, may facilitate nurses with successful grieving. 16 Eakes 17 found that clearly es- tablishing new treatment goals, i.e., shifting from curative to palliative focus, assisted nurses in their grief. The study was based on nurses in a palliative care setting, and thus it is not known if acute care nurses would have the same experience.

Spencer 18explored how nurses dealt with their own grief when a patient died on an ICU and what factors helped them effectively overcome their grief. The data were obtained from survey questionnaires completed by 72 nurses. In-depth interviews were also carried out with 10 nurses to more fully explore their question- naire responses. The investigator found that nurses experienced a variety of feelings—including sadness, shock, anger, and relief—when a patient dies. Only a few nurses reported feeling guilty after a patient death.

Nurses reported that they received peer support in the form of informal discussions with colleagues. The re- sults revealed that the majority of nurses had no formal training in the area of death and dying. Last, nurses believed that chatting informally with peers was an adequate means for obtaining support after a patient death. Although these data are interesting, the survey method of data collection was limiting. It is unclear how the in-depth interviews were performed or who was selected to participate in the interviews.

There was also no exploration of what “peer support” meant or what issues were commonly discussed. Coping strategies used by MICU nurses Badger 64 www.heartandlung.org JANUARY/FEBRUARY 2005 HEART & LUNG Saunders and Valente 19 reported that most nurses believed that they managed their grief better if they helped a patient die a “good” death. They defined a good death as having the following char- acteristics: (1) the nurse had relieved the patient’s distress and symptoms to the best of her or his knowledge and use of current resources; (2) the patient had the opportunity to reach closure with important relationships; (3) the nurse believed that he or she had delivered the best quality of care for the patient; (4) the patient’s death did not violate natural order (referring to age at time of death;, and (5) the death was contextually appropriate (ex- pected given the circumstances). SETTING AND PARTICIPANTS The aim of this study was to describe MICU nurses’ coping behaviors while caring for a patient whose medical treatment transitioned from cure- to comfort-oriented care. The study took place in an 18-bed MICU that was part of a 719-bed acute care hospital located in the northeastern United States.

MICU nurses were specifically selected for this study because of their first-hand knowledge of working with critically ill patients and subsequently high likelihood of experiencing the dying process of pa- tients. Nineteen female and 5 male nurses partici- pated in the study. Data collection The nurse researcher and an assistant group moderator collected the data. The male nurse re- searcher was an experienced consultation-liaison psychiatric advanced practice nurse with group psy- chotherapy training. The group moderator was a female doctorally prepared cultural anthropologist with extensive focus-group experience.

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

All participants were asked to complete a brief pregroup questionnaire. This data was complied and used to provide aggregate descriptive informa- tion about the personal characteristics of the MICU staff including age, sex, ethnic origin, marital status, highest level of nursing education, years in general nursing, and years of experience in critical care.Focus-group interviews were recorded with au- diotape and brief written notes. Audiotapes were transcribed verbatim after each group session by a professional transcriber. The group size averaged between 4 and 5 participants/session. To allow flex- ibility of attendance, 5 group sessions were offered at different times during the 6-week period. Group interview sessions were held in the MICU confer- ence room so staff members could remain near critically ill patients while on duty. Ethical considerations There was the possibility that participants could experience some emotional discomfort when discussing their clinical experiences with critically ill patients. However, it was not expected that staff would become emotionally over- whelmed or experience significant psychological symptoms as a result of these discussions. None- theless, participants who reported significant dis- tress would be encouraged to seek professional counseling through a referral to the hospital’s employee assistance program. Analysis The analysis process consisted of compiling de- mographic data from all participants, transcribing audiotape recordings of group sessions, and review- ing data obtained from observational field notes.

This analysis began as the data were being gathered and was a continuous process throughout the data collection period. The process for the analysis of transcripts and audiotapes generally followed the method described by Miles and Huberman, 20 who divided the process of analysis into 3 major phases including data reduction, data display, and conclu- sion drawing.

First, the massive amount of data was organized into initial categories that were pre-established based on the research questions. This data reduc- tion process required the researcher to make deci- sions about how the data would be emphasized, minimized, or set aside completely to better focus on the purposes of the research investigation.

Throughout this process, however, the researcher remained open to the discovery of new meanings that might emerge unexpectedly from the data.

Next, data display provided the opportunity to fur- ther organize the data by compressing information to facilitate conclusion drawing. This was accom- plished by developing a chart that provided a new way of arranging and thinking about the more tex- tually embedded data. This data-display process Badger Coping strategies used by MICU nurses HEART & LUNG VOL. 34, NO. 1 www.heartandlung.org 65 allowed the researcher to discern systematic pat- terns and interrelationships. Charting enabled the researcher to develop more refined levels of cate- gories and themes as they emerged from the data.

The last phase of the data analysis process is what Miles and Huberman 20 referred to as “conclu- sion drawing.” This involved the researcher stepping back to consider what the analyzed data meant and to assess its implications for the original research questions. Simultaneously, verification involved the cross-checking or revisiting of data to verify any emergent conclusion as being true.

The group moderator assisted with the primary analysis of data. The assistant moderator performed an independent review based on the suggestion of Crawford and Acorn. 21 Discussion by both parties served to verify the themes, patterns, and catego- ries. Additionally, as recommended by McDaniel and Bach, 22 researchers returned to the audiotapes to validate the categories based on voice inflection and content. This process was repeated after leaving the information alone for several weeks. This fresh look after a period of absence from the data was thought to help in decreasing the number of cate- gories caused by overlapping data. FINDINGS Demographic data Twenty-four of 44 MICU nurses, comprising 19 female and 5 male participants, took part in this research investigation. One participant did not com- plete the demographic questionnaire. For the re- mainder of group participants, the mean age for the group was 38.7 years (range 24 to 57). Fourteen nurses were married, 8 were single, and 1 was di- vorced. All of the group participants were white. Of the group, 13 had a bachelor’s of science degree in nursing; 7 had an associate’s degree in nursing; and 2 had a nursing diploma degree. Years in the nurs- ing profession ranged from 1 to 35 years (mean 13.37). Similarly, the range of experience in MICU nursing varied from 1month to 35 years (mean 9.44). Coping strategies Nurses used a wide variety of different coping strategies to deal with complex patient care situa- tions occurring on the MICU. These strategies were initially described in terms of general thoughts and actions but were later divided into 3 major catego- ries including cognitive, affective, and behavioral techniques. Cognitive strategies included “putting up with it,” visualizing, learning from experience, reminiscing, and putting things into perspective.Putting up with it referred to the belief that “in essence it’s coming [death] so it’s just a matter of time. It’s just eight or it’s twelve hours knowing in the end it’s not going to make a bit of difference [what we do].” Visualizing was a technique used to remain em- pathetic. One nurse reported, “I just kept picturing my brother, my sister, my mother there [in bed] and it kind of gave empathy toward the family and the patient. I always tell myself that it’s a very hard decision to make.” Learning from experience, “You incorporate different things into your nursing [prac- tice]. Kind of look for things or kind of pick up on something from [the] family’s experiences.” Addi- tionally, “you appreciate life more because it could be us one day.” Visual images are often used as a means to help “you remember what you’re taking care of it gives you empathy.” When nurses look at their critically ill patients, they do not see the same image that the family is holding on to; placing a recent photograph in the room helps nurses to “per- sonalize a patient.” Reminiscing was a process of remembering past patient care experiences. One participant stated, “Every now and then we’ll talk about somebody really sad. We talk about if we did our best. We still talk about patients from years ago that we remem- ber, [especially] if there’s somebody with the same disease.” For example, “the guy who worked for his family, had two kids, just bought a boat, has leuke- mia and dies.” Last, putting things into perspective referred to “do your best not to take it personally.

You don’t take it home with you. You leave it.” Affective strategies included laughter, externaliz- ing feelings, and emotionally compartmentalizing.

Several group participants stated, “we laugh a lot” and have a “sick sense of humor, making jokes out of what are in reality dreadful situations.” Laughter is often used to mitigate the tension that results from toxic interactions with “pain-in-the-ass fami- lies and patients.” For example, “we’ll go into the backroom” and “say that the family is full of a bunch of nuts they are all crazy.” Occasionally, the staff will capitalize on an event that happened on the unit. This was exemplified when “someone com- plained about us, we looked like we never ironed our uniforms. So the night shift made a bunch of cut-out ironing boards and hung them from the ceiling [in our break room].” However, there were clear boundaries about what topics were considered off limits for humor. Many staff members stated, “[we] never joke about some- thing serious” and, in particular, “not about ‘unfair’ deaths, deaths of young or endearing patients.” Ex- Coping strategies used by MICU nurses Badger 66 www.heartandlung.org JANUARY/FEBRUARY 2005 HEART & LUNG ternalizing feelings allowed nurses to “verbalize to each other” or have a “group session.” This was particularly beneficial when dealing with difficult patients and families. The “group session” provided a safe place to air complaints as well as a forum for seeking aid from peers, such as by stating, “I won’t take that patient back tomorrow.” In response, col- leagues would offer to be assigned to that patient the next day. Most nurses reported, however, “it’s not that patient nine out of ten times [that is the problem] it is [dealing with] the family.” Thus, “everybody rotates through and takes their turn” with difficult families. Colleagues and peers pro- vided the main audiences for gripes, frustrations, and target for voicing difficult feelings.

Most nurses acknowledged, “I really don’t talk about my job a lot when I get home because I feel like a lot of [what happens on the unit] is just a big downer for everybody else that’s going to listen to me.” One nurse said, “You do what you have to do to internalize it. Just kind of separate yourself. People don’t want to hear, well, ‘I terminally extubated someone today.’ People don’t talk about that stuff [so you] kind of keep that to yourself.” Behavioral strategies included retreating, avoid- ing, and distancing behaviors. Retreating referred to being “fired” or dismissed from the patient care assignment as well as having to just “walk away” for reasons of personal frustration or distress. Being fired was a relatively common experience for MICU staff members. It usually occurred “not because you said anything worse than the person before you it was just the last time that the person wanted to hear it for whatever reason. That’s okay, somebody else takes over.” In addition to more formal coping strategies, nurses also reported that the use of faith, existential beliefs, and mutual support were beneficial. Most participants commented, “We really have a great group up here because we deal with life and death.

We’re all pretty close with each other. Everyone here has been through it [caring for the dying patient and grieving family] so they know [what it is all about].” Distancing behaviors were commonly used to get a break from overbearing families. One nurse stated, “It’s amazing how much stress you get rid of when you get [the family] out of the way. You close the door, get them out of the room, out of your personal space, and do things with your patient.” Being an MICU nurse also provided a sense of pride for staff.

Several nurses commented, “You know that your opinions are valued” and you are “more respected [here in the MICU].” They were proud that their particular unit was “nationally recognized for ourquality of end-of-life-care” and they held themselves to a “very high standard.” Last, one nurse stated, “One thing that attracts me to this job is the fact that nobody else would want to do it. If I can work in this place that’s kind of cool because other people can’t do it.” Nurses commonly cited providing futile care and the perception of “torturing the patient” as 2 of the more distressing situations that they encounter while providing care on the MICU. Many nurses stated, “the hardest thing to do is keep intervening with a patient whose is clearly dying so as to pre- vent a natural death.” Most staff acknowledged that “we have the technology to keep people alive forever we keep going on and on” ultimately, “quality [of life] becomes the issue.” The experience of “tortur- ing the patient” was exemplified by one nurse who stated, “I feel like I am torturing the patient, keeping whomever alive beyond their time not for the pa- tient or what the patient would want, but for other people because the family can’t let go.” Many nurses felt “you’re not prolonging life but rather just prolonging misery.” Another difficult clinical situation involved facil- itating communication between families and medi- cal staff. Nurses reported being frustrated by “going forth causing discomfort to the patient when some- times the physicians needed to be a little more aggressive in talking with the family and being hon- est on what the outcome will be.” Yet another nurse remarked, “sometimes you just don’t get the answer you want.” Although some focus group discussions were emotionally intense, no research participant expe- rienced sustained emotional distress to warrant re- ferral for formal psychological treatment. This type of emotional response was not unexpected based on prior experience with other critical care nurses.

Staff members generally appreciated the opportu- nity to talk about their work-related clinical experi- ences and reactions. DISCUSSION Nurses commonly used a variety of coping behav- iors to maintain a professional demeanor during their interactions with patients, other health professionals, or family members. Staff commonly acknowledged that personal grief reactions were experienced but not discussed overtly unless the death involved a young or endearing patient. Consistent with Kirchhoff and Beck- strand 13 and Davies et al., 12 these nurses reported difficulty when providing care to dying patients, pri- marily as the result of conflicts that arose because of Badger Coping strategies used by MICU nurses HEART & LUNG VOL. 34, NO. 1 www.heartandlung.org 67 families and physicians. Indeed, futile care and the perception of “torturing the patient” caused the great- est amount of distress for staff.

MICU nurses commonly believed that emotional reactions to patient care situations were best shared with one’s own MICU colleagues. They usually did not share their work-related experiences with family mem- bers; they avoided “outsider” emotional support and did not seek referral for professional counseling ser- vices. This was consistent with the findings of Spen- cer 18 that nurses often believed that chatting infor- mally with peers was an adequate means for obtaining emotional support. Study limitations The major limitation of this research investigation was that the experiences of staff members of this particular MICU might be unique to this unit and not reflective of the views or experiences of other MICU staff. This MICU was a unique environment for several reasons: (1) the staff had worked together for many years, and the nurse leaders group worked closely with them and (2) the unit medical director was involved with research about end-of-life issues. Together these factors may have had an impact on how the nurses dealt with end-of-life concerns or at least have influ- enced their beliefs. The entire sample was composed of white nurses and, as such, this may have restricted any opportunity to obtain end-of-life viewpoints from other cultural perspectives. CONCLUSIONS MICU nurses used a variety of personal coping strategies when confronted with the emotional de- mand of complex patient care situations. These cop- ing strategies were comprised of a combination of cognitive, affective, and behavioral techniques. Nurses used several cognitive strategies that included “put- ting up with it,” visualizing, learning from the experi- ence, reminiscing, and putting things into perspective.

Laughter, externalizing, or internalizing feelings were helpful affective strategies used to control distress.

Behavioral strategies consisted primarily of retreating, avoidance, or selective distancing behaviors. Being a MICU nurse in and of itself provided a sense of pride for staff. Most believed that their clinical opinions were valued and that they were respected as profes- sionals. MICU nurses are confronted with a multitude of distressing clinical situations, but they reported the most emotional distress when providing futile care, feeling that they are “torturing” the patient by provid-ing aggressive care, and when dealing with difficult families. I thank Mitchell Levy, MD, Susan Ross RN, and Donna Haze, RN, for their administrative support of this research investigation. I also thank the MICU nursing staff for sharing their personal experiences and participating in the study. REFERENCES 1. Faber-Langendoen K, Lanken PN. Dying patients in the in- tensive care unit: forgoing treatment, maintaining care. Ann Intern Med 2000;133:886-93.

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