Nurses’ Experience With End-of-Life Care in Geriatric Centers: A Systematic Review

Research Question

In a systematic review, what is the evidence on the experiences of geriatric nurses with emotions and feelings such as moral distress, grief, and compassion fatigue related to end-of-life?

Research Objectives

Justification for a Systematic Review Methodology

A systematic review is an excellent opportunity for using available evidence to clarify phenomena. In this assessment, this methodological approach provides an avenue for critically assessing available literature on the emotional experiences of geriatric nurses during end-of-life. It aligns with the research question and objectives by incorporating evidence from multiple databases. During data collection, it considers inclusion and exclusion criteria for different sources of evidence. As such, it provides an avenue for acknowledge findings essential to clinical practice and policy recommendations. A review was not registered and a review protocol was not prepared.

Review of Literature

Geriatric nurses provide quality, safe, and effective care to elderly patients. This care influences the behaviors of geriatric nurses when attending to patients (Hussain, 2021). Some of the complex practicalities in end-of-life care are burnout, moral distress, compassion fatigue, and anxiety (Hussain, 2021). In the wake of the COVID-19 pandemic, geriatric nurses changed their behaviors when managing elderly patients (Rababa et al., 2022). Due to the pandemic, geriatric nurses attending to elderly patients developed anxiety. These issues necessitated the development of a supportive workplace and psychological interventions to boost geriatric nurses’ morale when caring for end-of-life patients (Hussain, 2021; Rababa et al., 2022).

The pandemic caused emotional turmoil to geriatric nurses across the globe. Emotional exhaustion, lack of professional commitment, and fear of the pandemic characterized geriatric nurses’ emotional challenges (Sarabia-Cobo et al., 2021b). This situation called for novel models of care in healthcare facilities to boost the delivery of quality patient care. Due to the extensive workload, geriatric nurses felt overwhelmed taking care of end-of-life patients (Sarabia-Cobo et al., 2021b). They provided sufficient care to these patients regardless of the prevailing circumstances (Peker et al., 2021).

These emotions affected geriatric nurses in equal measures to patients. Regardless of geriatric nurses’ efforts to safeguard geriatric patients’ lives, especially in the intensive care unit, some patients were on end-of-life (Kostka et al., 2021). End-of-life situations contributed to geriatric nurses’ emotions, such as sadness and helplessness (Kostka et al., 2021). The nurses required effective coping strategies when dealing with end-of-life patients. Failure to provide coping strategies lowered geriatric nurses’ wellbeing and impeded the provision of quality end-of-life care (Zhang et al., 2022).

Although attitudes toward end-of-life vary significantly across nurses, it is essential to develop effective coping strategies such as psychological support and regular training on handling end-of-life (Cybulska et al., 2022). End-of-life is part of life, but most people are uncomfortable when it approaches. For instance, nurses offering end-of-life care have a stressful experience characterized by anxiety, distress, frustration, failure, and grief (Cybulska et al., 2022). Effective coping mechanisms enable geriatric nurses to offer holistic end-of-life care (Yi, 2021).

Search Strategy

The study involved a systematic review of the literature on nurses’ emotions and feelings when caring for end-of-life patients in geriatric centers. Systematic reviews provide an effective strategy for addressing research gaps in nursing (De Oliveira et al., 2019). The search process for literature materials for this systematic review followed a population, intervention, comparison, and outcome (PICO) question strategy. The PICO questions are paramount in establishing recovery-oriented, patient-centered, and evidence-based measures for improving healthcare activities (Eriksen & Frandsen, 2018). In line with these considerations, the PICO question is, “In a geriatric center, do nurses’ emotions and feelings compared to other clinical settings, influence nurses’ roles in promoting end-of-life care?”

Population: Geriatric nurses

Intervention: Emotions and feelings

Comparison: Other clinical settings, such as emergency departments, primary care settings, and intensive care units

Outcome: Nurses’ roles in promoting end-of-life care

Search Process

Scientific databases offer quality and comprehensive information on the emotions and feelings that geriatric nurses portray when attending to end-of-life elderly patients (Oermann et al., 2021). The selected databases were CINAHL, Cochrane Library, and PubMed. In addition, Google Scholar expanded the search attributes. These databases were last searched on April 4, 2024. Search terms were “geriatric nurses,” “emotions,” “feelings,” and “end-of-life.” They were subjected to their relative MeSH descriptors and Boolean operators “AND” and “OR” to foster intersectionality. These considerations offered an enabling basis for acquiring peer-reviewed and quality resources for the review.

Eligibility

The acquired literature materials were subjected to eligibility criteria. Eligibility is an effective strategy for acknowledging the materials to exclude and include in the study (Patino & Ferreira, 2018).

Methodological Quality

Critical Appraisal Skills Program (CASP) guidelines were used to confirm the reliability, quality, and vigor of the nine studies. These studies were subjected to different CASP tools to boost extensive and accurate assessment of their methodological quality. The findings from these assessments contributed to the inclusion of these nine articles in the systematic review.

Study Selection

Literature materials screened and included in the study were based on the eligibility criteria. Figure 1 provides a detailed PRISMA flow chart diagram evidencing the search process.

OPEN IN VIEWER

Figure 1.

A PRISMA chart for selecting literature materials for the study.

The search process led to the inclusion of nine studies in the systematic review. These articles provided in-depth information on the emotions and feelings of geriatric nurses in end-of-life. The study evaluated scientific materials about caring for geriatric patients from January 2018 to December 2023. The search process led to the discovery of sources on geriatric nurses’ emotions and feelings related to end-of-life. Figure 2 outlines the publication trend of the selected literature materials.

OPEN IN VIEWER

Figure 2.

Publication trend of the selected articles (2018–2023).

The articles involved diverse study designs to facilitate in-depth assessment of the emotions and feelings of geriatric nurses. These designs were ethnography, qualitative, mixed methods, and integrated, scoping, and literature review. Six studies had a sample size of 6 to 126 nurses while three studies involved review of articles. The three reviews offered an advanced basis for improving the understanding of the relationship between nurses’ emotions and feelings and the associated experiences. Accordingly, the use of nurses or geriatric nurses in the study was essential to boost understanding of the emotions and feelings since nurses are the primary care givers to geriatric patients at end-of-life. Table 1 categorizes the key methodological factors, findings, and limitations of the articles.

OPEN IN VIEWER

Table 1.

Article Categorization.

Article	Country	Study design	Sample size	Characteristics of end-of-life	Findings	Limitations
Ådland et al. (2022)	Norway	Ethnographic fieldwork	6 Nursing home staff	The study explored the emotional experiences of nurses caring for end-of-life patients	The study indicates tensions between distanced professionalism and emotional closeness when dealing with “special residents”	Limited generalizability of the findings due to the small sample size Publication bias
Lokker et al. (2018)	The Netherlands	Qualitative	36 Nurses	The study explored how nurses experienced emotions when administering palliative sedation	Nurses experience moral distress in instances where they cannot act in the patient's best interest	Limited generalizability of the findings due to the small sample size Participant selection bias
Nikbakht Nasrabadi et al. (2021)	Iran	Qualitative phenomenological	9 ICU nurses	The study explored moral distress among nurses caring for elderly patients in the ICU	It acknowledges the importance of advocacy, defense mechanisms, and care burden	Subjective nature of the interpretations Limited generalizability due to small sample size
Spence et al. (2023)	The United States	Mixed methods	126 Interns and nurses	The study explored moral distress among interns and nurses caring for end-of-life patients	Interns and nurses experience moral distress when caring for palliative patients	The small sample size leads to generalizability limitations Self-reported surveys cause response bias
Cross (2019)	Jordan	Qualitative	21 Jordanian nurses	The study explored compassion fatigue among palliative care nurses	Across the globe, nurses face a wide array of challenges. These challenges influence their ability to provide quality, safe, and effective healthcare services	The limited scope of the literature reviewed Potential bias of participants Limited generalizability due to small sample size
Khalaf et al. (2018)	N/A	Qualitative phenomenological	17 Studies	The study explored the lived experiences of nurses after end-of-life	End-of-life leads to nurses’ grief. This occurrence calls for developing effective coping strategies to overcome the grief period holistically	Potential selection bias Limited generalizability of findings
Yu et al. (2023)	N/A	Scoping review	Studies on burnout among nurses attending to elderly patients	The study explored workplace burnout among nurses caring for end-of-life patients	The workplace issues related to burnout are psychological harm, inexperience, and negative emotions	Potential selection bias Publication bias
Harrad and Sulla (2018)	N/A	Literature review	35 Studies	The study explored nursing burnout among residential home care workers for elderly patients	The identified issues related to burnout are staff perceptions, training, and coping strategies	Potential selection bias Publication bias
Bloomer et al. (2023)	Portugal	Structured integrative review	6 Nurses	The study explored the experiences of nurses after end-of-life	It identified nurses’ emotional responses to end-of-life, the required support, and the importance of postmortem care	Potential selection bias Limited generalizability due to small sample size

Article categorization based on limitations, findings, and methodological considerations such as objectives, study design, and sample size.

Summary of Findings

The study found out that geriatric nurses experience challenges when provide patient care. These challenges influence the ability of nurses to provide quality, safe, and effective services (Cross, 2019). An excellent example of an issue that affects the quality of care that patients receive is the tension between distanced professionalism and emotional closeness. It is important to note that emotional closeness between nurses and geriatric patients contribute to moral distress (Ådland et al., 2022; Lokker et al., 2018; Spence et al., 2023). The moral distress is common when providing end-of-life care to geriatric patients (Bloomer et al., 2023). An excellent example of moral distress among geriatric patients is grieving (Khalaf et al., 2018). In most cases, these emotions emerge from burnout when caring for patients in which nurses have emotional closeness. Some of the common issues related to burnout are inexperience, staff perception, and psychological harm (Harrad & Sulla, 2018; Yu et al., 2023). These issues necessitate the development of measures to cope with the emotional challenges such as advocacy for nurses’ emotional wellbeing (Nikbakht Nasrabadi et al., 2021).

Geriatric nurses promote the mental, physical, and emotional wellbeing of elderly patients hospitalized in a geriatric center (Ådland et al., 2022; Nikbakht Nasrabadi et al., 2021). However, they witness emotionally challenging situations such as end-of-life. This encounter leads to compassion fatigue, moral distress, grief, and burnout (Cherny et al., 2021). Geriatric nurses develop emotional and physical exhaustion from prolonged exposure to geriatric patients (Cross, 2019). These patients experience immense suffering, which leads to their emotional distress. As such, geriatric nurses encounter stressful situations due to the physical, mental, and emotional distortions that elderly patients experience while in geriatric care centers (Cross, 2019; Spence et al., 2023).

Nurses experiencing emotional and physical exhaustion have symptoms. Some of these symptoms are cynical and pessimistic behaviors toward patient care, emotional detachment from the patients, stress management challenges, and depersonalized feelings (Borges et al., 2019; Lokker et al., 2018). In line with these occurrences, geriatric nurses experience compassion fatigue while caring for elderly patients. This experience affects their ability to deliver quality, safe, and effective healthcare services to these patients (Gustafsson & Hemberg, 2022). Compassion fatigue contributes to moral distress among nurses when caring for suffering patients. Moral distress is a conflict between doing the right thing and following regulatory protocol, constraints, or external pressures (Young et al., 2017).

In geriatric care, nurses may participate in interventions against patients’ wishes. Resource limitations create constraints, which leads to unethical care among geriatric nurses (Cross, 2019; Nikbakht Nasrabadi et al., 2021). These occurrences may contribute to end-of-life, which the nurse has no potential to overcome. As such, this situation creates moral distress characterized by frustration, anger, guilt, and helplessness (Spence et al., 2023). The failure to manage moral distress leads to burnout among geriatric nurses. Burnout is a state of physical, mental, and emotional exhaustion due to prolonged stress (Boerner et al., 2017).

Burnout stems from multiple issues when caring for end-of-life geriatric patients. Some of these issues are feeling misunderstood, inadequate resources, high workloads, and the emotional demands of caring for end-of-life patients (Yu et al., 2023). In most cases, geriatric nurses experience a wide array of symptoms before the onset of burnout. These symptoms are exhaustion, demotivation, cynicism, and a decreased sense of accomplishment (Harrad & Sulla, 2018; Yu et al., 2023). Burnout may emerge among geriatric nurses in the form of stomachaches, headaches, or sleep disturbances. In some circumstances, burnout relates to grief, which is a natural emotional response among nurses attending to end-of-life patients (Kostka et al., 2021). Some of these circumstances are anticipatory painful end-of-life, intense grief after end-of-life, and chronic sadness for end-of-life (Hawes & Wang, 2023; Kostka et al., 2021).

Grief manifests in a wide array of mechanisms. For instance, nurses may experience tearfulness, sadness, and emotional outbursts (Hawes & Wang, 2023). They may also experience sleep disturbances, physical pains, and appetite changes (Khalaf et al., 2018). Due to end-of-life, geriatric nurses withdraw immensely from social activities due to the related decision-making difficulties (Bloomer et al., 2023; Khalaf et al., 2018). These emotional experiences are normal reactions to the demanding work of the nurses. In line with this consideration, nurses should strive to maintain emotional wellbeing (Bloomer et al., 2023). This situation will contribute immensely to providing quality, safe, and effective care to geriatric patients.

Limitations

A comprehensive systematic review offers evidence-based information on the emotions and feelings of nurses caring for end-of-life elderly patients (Ahn & Kang, 2018). However, the study has multiple limitations. For instance, it has a possible bias in the search process due to overreliance on a few databases and excluding grey literature. It also has methodological limitations of the selected literature materials. It is also important to note that the study has generalizability, contextual, and interpretation limitations. As such, future studies should embark on measures addressing attribution bias and the limited applicability of the findings.

Implications

The findings of this study provide a basis for improving patient care. They necessitate the application of evidence-based interventions to boost patient-centered care. A fundamental factor is training nurses on communication skills to promote continuity of care (Sheehan et al., 2021). The nurses will also require training on stress management to address fatigue at workplace. In addition, the study calls for resilience and coping mechanisms for nurses attending to end-of-life patients. It necessitates nurse training on mindfulness and stress-reduction measures to manage their emotional demands (Wang et al., 2023). The effective management of emotional demands will enable geriatric nurses to overcome burnout in the workplace. They should also call for flexible work arrangements to reduce stress and overcome burnout. For instance, the nurses engage in teamwork to provide mutual support and emotional burdens when caring for end-of-life patients. They should also participate in support groups and counseling services to overcome challenges emerging from grief and moral distress. Therefore, assessing nurses’ emotions and feelings on managing end-of-life patients is paramount in the contemporary nursing world.