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Time and life is fragile”: An integrative review of nurses’ experiences after patient death in adult critical care

  • Melissa J. Bloomer
    Correspondence
    Corresponding author.
    Affiliations
    End of Life Advisory Panel, Australian College of Critical Care Nurses, Victoria, Australia

    Menzies Health Institute Queensland, Griffith University, Queensland, Australia

    School of Nursing & Midwifery, Griffith University, Queensland, Australia

    Intensive Care Unit, Princess Alexandra Hospital, Metro South Health, Queensland Health, Queensland, Australia
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  • Kristen Ranse
    Affiliations
    End of Life Advisory Panel, Australian College of Critical Care Nurses, Victoria, Australia

    Menzies Health Institute Queensland, Griffith University, Queensland, Australia

    School of Nursing & Midwifery, Griffith University, Queensland, Australia
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  • Leah Adams
    Affiliations
    End of Life Advisory Panel, Australian College of Critical Care Nurses, Victoria, Australia

    Intensive Care Unit, Latrobe Regional Hospital, Victoria, Australia
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  • Laura Brooks
    Affiliations
    End of Life Advisory Panel, Australian College of Critical Care Nurses, Victoria, Australia

    School of Nursing and Midwifery, Deakin University, Victoria, Australia

    Centre for Quality and Patient Safety Research, Deakin University, Victoria, Australia
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  • Alysia Coventry
    Affiliations
    End of Life Advisory Panel, Australian College of Critical Care Nurses, Victoria, Australia

    St Vincent's Health Network Sydney, St Vincent's Hospital, Melbourne and Australian Catholic University, Australia
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Open AccessPublished:November 09, 2022DOI:https://doi.org/10.1016/j.aucc.2022.09.008

      Abstract

      Introduction

      Providing bereavement support and care to families is an aspect of critical care nursing practice that can be rewarding, yet emotionally and psychologically challenging. Whilst significant research has focused on end-of-life care in critical care, less is known about nurses’ experiences after patient death.

      Aim

      The aim of this study was to synthesise research evidence on the experience of registered nurses after patient death in adult critical care.

      Design

      A structured integrative review of the empirical literature was undertaken. A combination of keywords, synonyms, and Medical Subject Headings were used across the Cumulative Index Nursing and Allied Health Literature (CINAHL) Complete, Ovid Medline, PsycInfo, Embase, and Emcare databases. Records were independently assessed against inclusion and exclusion criteria. A process of forward and backward chaining was used to identify additional papers. All papers were assessed for quality. Narrative synthesis was used to analyse and present the findings.

      Results

      From the 4643 records eligible for screening, 36 papers reporting 35 studies were included in this review, representing the voices of 1687 nurses from more than 20 countries. Narrative synthesis revealed three themes: (i) postmortem care, which encompassed demonstrating respect and dignity for the deceased, preparation of the deceased, and the concurrent death rituals performed by nurses; (ii) critical care nurses' support of bereaved families, including families of potential organ donors and the system pressures that impeded family support; and (iii) nurses’ emotional response to patient death including coping mechanisms.

      Conclusions

      Whilst a focus on the provision of high-quality end-of-life care should always remain a priority in critical care nursing, recognising the importance of after-death care for the patient, family and self is equally important. Acknowledging their experience, access to formal education and experiential learning and formal and informal supports to aid self-care are imperative.

      Keywords

      1. Introduction

      Death in critical care settings is common.
      • Sadler E.
      • Hales B.
      • Henry B.
      • Xiong W.
      • Myers J.
      • Wynnychuk L.
      • et al.
      Factors affecting family satisfaction with inpatient end-of-life care.
      Mortality in patients admitted to adult critical care ranges from 10 to 29%.

      Society of Critical Care Medicine. Critical Care Statistics 2022. Available from: https://www.sccm.org/Communications/Critical-Care-Statistics.

      The provision of end-of-life care is a core component of critical care nursing practice,
      • Coombs M.
      • Fulbrook P.
      • Donovan S.
      • Tester R.
      • deVries K.
      Certainty and uncertainty about end of life care nursing practices in New Zealand Intensive Care Units: a mixed methods study.
      with critical care nurses estimated to encounter an average of two patient deaths each week.
      The Faculty of Intensive Care Medicine
      Care at the end of life: a guide to best practice, discussion and decision-making in and around critical care.
      Importantly, care does not end at patient death.
      • Efstathiou N.
      • Walker W.
      • Metcalfe A.
      • Vanderspank-Wright B.
      The state of bereavement support in adult intensive care: a systematic review and narrative synthesis.
      Rather, nursing care continues after death to include preparation of the body, supporting cultural and religious needs, facilitating wishes and customs, and providing practical guidance about the next steps.
      • Bloomer M.J.
      • Ranse K.
      • Butler A.
      • Brooks L.
      A national Position Statement on adult end-of-life care in critical care.
      • Coombs M.A.
      • Addington-Hall J.
      • Long-Sutehall T.
      Challenges in transition from intervention to end of life care in intensive care: a qualitative study.
      The care provided to patients and their families during dying, death, and bereavement can be emotionally and psychologically demanding for critical care nurses.
      • White D.
      • Meeker M.A.
      Guiding the process of dying: the personal impact on nurses.
      ,
      • Stayt L.C.
      Death, empathy and self preservation: the emotional labour of caring for families of the critically ill in adult intensive care.
      The wider nursing literature demonstrates that not all nurses are adequately prepared to cope with patient death.
      • Zheng R.
      • Lee S.F.
      • Bloomer M.J.
      How nurses cope with patient death: a systematic review and qualitative meta-synthesis.
      Competing clinical demands, workload pressures, and complex clinical environments contribute to concerns about the quality of bereavement support critical care nurses provide to families after a death.
      • Raymond A.
      • Lee S.F.
      • Bloomer M.J.
      Understanding the bereavement care roles of nurses within acute care: a systematic review.
      In addition, a lack of opportunities for experiential learning contributed to critical care nurses not being adequately prepared to provide immediate grief and bereavement support for family members after death.
      • Bloomer M.J.
      • Morphet J.
      • O'Connor M.
      • Lee S.
      • Griffiths D.
      Nursing care of the family before and after a death in the ICU—an exploratory pilot study.
      Although care of the deceased patient and their family remain the priority, in order to provide optimal care after a death, nurses must also prioritise self-care.
      • Walker W.
      • Efstathiou N.
      Support after patient death in the intensive care unit: why ‘I’ is an important letter in grief.
      Whilst guidelines and position statements are available to guide the provision of high-quality end-of-life care,
      • Bloomer M.J.
      • Ranse K.
      • Butler A.
      • Brooks L.
      A national Position Statement on adult end-of-life care in critical care.
      ,
      Australian Commission on Safety and Quality in Health Care
      National consensus statement: essential elements for safe and high-quality end-of-life care.
      there is a paucity of research evidence or practice guidelines specific to postmortem nursing practice in critical care, including care of the family and self. Therefore, the aim of this integrative review was to synthesise research evidence on registered nurses’ experiences after patient death in adult critical care.

      2. Methods

      2.1 Aim

      The aim of this study was to synthesise research evidence on the experience of the nurse after the death of a patient in adult critical care.

      2.2 Review question

      The research question was ‘What is the experience of the nurse after the death of a patient in adult critical care in relation to (i) postmortem care of the deceased person, (ii) communicating and documenting patient death, (iii) the breadth of family support provided by the nurse, (iv) nurses’ response to patient death, and (v) coping and self-care?’

      2.3 Design

      An integrative review with narrative synthesis was selected to investigate the research question. A narrative synthesis approach
      • Popay J.
      • Roberts H.
      • Sowden A.
      • Petticrew M.
      • Arai L.
      • Rodgers M.
      • et al.
      Guidance on the conduct of narrative synthesis in systematic reviews.
      was considered most appropriate due to the exploratory nature of the research question and the anticipated descriptive qualitative data. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was used to guide reporting of this review.
      Equator Network
      Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      A protocol was registered with PROSPERO (2021 CRD42021271521).
      • Bloomer M.
      • Adams L.
      • Brooks L.
      • Coventry A.
      • Ranse K.
      Registered nurses' experiences after the death of a patient in adult critical care [Protocol].

      2.3.1 Inclusion and exclusion criteria

      Studies were considered for inclusion if they reported data about the experience of registered nurses after patient death in relation to (i) postmortem care, (ii) communicating and documenting patient death, (iii) family support, and (iv) nurses’ emotional response to patient death, self-care strategies, and/or available supports in the adult critical care setting (Table 1). Peer-reviewed qualitative, quantitative, and mixed-methods studies published in English language from inception to August 2021 were eligible for inclusion. Research related to neonatal and paediatric populations were excluded because they focus on involving, informing, and supporting parents, which is outside the scope of this review. Grey literature including theses and dissertations, nonresearch publications, and studies conducted in mixed settings where data could not be separated were excluded.
      Table 1Search terms.
      TermMeSHKeyword
      “After death”OR“Social support”

      Bereavement

      “Psychosocial support system”

      “Self-care”
      OR“After-death care”

      “Post-mortem”

      “bereavement support”

      “Psych∗ support”

      “spiritual support” debrief∗

      support∗

      counsel∗
      AND
      “Critical care”OR“Intensive care”ORICU

      CCU

      HDU

      ITU

      “intensive therapy unit”

      “high dependency unit”
      AND
      NurseOR“registered nurs∗”

      “Nursing staffs”

      “Nurse clinicians”

      “health personnel”

      Caregiv∗
      ORNurs∗

      2.3.2 Search strategy and information sources

      In August 2021, a systematic search of five databases was undertaken including Cumulative Index for Nursing and Allied Health (CINAHL) Complete, Ovid Medline, APA PsycInfo, Embase, and Emcare. No publication date limits were applied to the searches to ensure all primary research evidence related to the research question was captured. All relevant words and synonyms for the concepts ‘after death’, ‘critical care’, and ‘nurse’ were searched to explore the topic as comprehensively as possible. Searches for each concept were run using OR with database-specific MeSH heading and synonyms and then combined using AND to identify papers describing the experience of nurses after patient death in critical care (Table 1). The search was limited to English language only. The CINAHL search is provided as an exemplar in Appendix 1.

      2.4 Study selection

      The citations of all retrieved studies were imported into Endnote, Version 20,
      The EndNote Team
      EndNote.
      followed by the removal of duplicate citations. In line with the aim and inclusion and exclusion criteria of this review, papers that contained the words ‘paediatric’, ‘pediatric’, ‘neonat∗’, ‘PICU’, or ‘NICU’ in the title were excluded. The EndNote library was then exported into Covidence,
      Veritas Health Innovation
      Covidence.
      where additional duplicate records were identified and removed.
      Title and abstract screening was undertaken in Covidence
      Veritas Health Innovation
      Covidence.
      by two members of the research team, independently. Adjudication of any discrepancies was undertaken by a third research team member. Double-blind full-text review was then undertaken, and any paper that did not match the eligibility criteria (Table 2) was excluded. In addition to the original database searching, forward and backward chaining of included papers, which involved reviewing papers cited by included papers and papers that cited included papers for other potential papers, was undertaken. Two additional papers were identified that met the inclusion criteria: one was included; however, a full text was not available for the second, so it was excluded. A PRISMA flowchart documenting the results of the search and screening process is provided in Fig. 1.
      Table 2Inclusion and exclusion criteria.
      Inclusion criteriaExclusion criteria
      Determined by Title and Abstract:
      • Study Designs: Primary qualitative, quantitative or mixed methods studies reporting peer-reviewed research
      • Study Populations: Registered nurses working in adult critical care settings
      • Study Settings: adult critical care, intensive care, or intensive therapy units
      • Study Focus: experience of the nurse after the death of a patient
      Determined by Full Paper:Focus #1: Data about the experience of nurses after patient death in critical care. Types of data may include, but are not limited to:
      • Post-mortem care of the deceased person and family
      • Communicating and documenting patient death
      • Practical, social, emotional, or spiritual support provided to family and clinicians
      AND/ORFocus #2: Data about nurses' emotional/psychological response to patient death and self-care, including, but not limited to:
      • Self-care strategies such as exercise, debriefing, seeking comfort from others
      • Availability of and use of workplace supports e.g., debriefing programs, counselling or informal supports, and self-care
      Language: EnglishPublication year: Inception – August 2021
      • Studies conducted in neonatal or paediatric settings.
      • Studies conducted in mixed (adult/paediatric/neonatal) settings where the data cannot be separated.
      • Reviews: Systematic, literature, scoping reviews.
      • Nonresearch publication: Abstracts, conference papers, letters to the editor, commentary, and opinion pieces.
      • Grey literature: Theses and dissertations.
      Figure 1
      Fig. 1PRISMA flow diagram Reproduced from Moher, Liberati, Tetzlaff, and Altman, The PRISMA Group (2009) [Colour figure can be viewed at wileyonlinelibrary.com].

      2.5 Data extraction and quality appraisal

      Data were extracted from the included studies by two researchers using a standardised template developed by the review team, with 40% of papers independently checked for consistency. The quality of all included papers was independently assessed by two researchers using a tool suitable for qualitative and quantitative research.
      • Caldwell K.
      • Henshaw L.
      • Taylor G.
      Developing a framework for critiquing health research: an early evaluation.
      An a priori decision was made to not exclude papers based on quality appraisal scores but instead to use the quality assessments to describe the quality of the research evidence.

      2.6 Data analysis

      Narrative synthesis, an approach that relies primarily on the use of words to explain and summarise synthesis findings,
      • Popay J.
      • Roberts H.
      • Sowden A.
      • Petticrew M.
      • Arai L.
      • Rodgers M.
      • et al.
      Guidance on the conduct of narrative synthesis in systematic reviews.
      was used to summarise heterogenous findings across study types, using text to emphasise similarities within and differences between the studies. Synthesis was initially undertaken by one researcher, then reviewed by a second researcher, with differences and disagreements discussed until the final synthesised findings were determined.

      3. Results

      This integrative review included 36 papers reporting 35 studies, published between 1994 and 2021; 28 were qualitative studies,
      • Stayt L.C.
      Death, empathy and self preservation: the emotional labour of caring for families of the critically ill in adult intensive care.
      ,
      • Bloomer M.J.
      • Morphet J.
      • O'Connor M.
      • Lee S.
      • Griffiths D.
      Nursing care of the family before and after a death in the ICU—an exploratory pilot study.
      ,
      • Andrew C.M.
      Optimizing the human experience: nursing the families of people who die in intensive care.
      • Benbenishty J.
      • Bennun M.
      • Lind R.
      Qualitative analysis of European and Middle East intensive care unit nursing death rituals.
      • Betriana F.
      • Kongsuwan W.
      Grief reactions and coping strategies of Muslim nurses dealing with death.
      • Bone N.
      • Swinton M.
      • Hoad N.
      • Toledo F.
      • Cook D.
      Critical care nurses' experiences with spiritual care: the SPIRIT study.
      • Çelik S.
      • Ugras G.A.
      • Durdu S.
      • Kubas M.
      • Aksoy G.
      Critical care nurses' knowledge about the care of deceased adult patients in an intensive care unit.
      • de Swardt C.
      • Fouché N.
      “What happens behind the curtains?” an exploration of ICU nurses' experiences of post mortem care on patients who have died in intensive care.
      • Forsberg A.
      • Flodén A.
      • Lennerling A.
      • Karlsson V.
      • Nilsson M.
      • Fridh I.
      The core of after death care in relation to organ donation–A grounded theory study.
      • Gélinas C.
      • Fillion L.
      • Robitaille M.-A.
      • Truchon M.
      Stressors experienced by nurses providing end-of-life palliative care in the intensive care unit.
      • Halcomb E.
      • Daly J.
      • Jackson D.
      • Davidson P.
      An insight into Australian nurses' experience of withdrawal/withholding of treatment in the ICU.
      • Hall M.A.
      Critical care registered nurses' preparedness in the provision of end-of-life care.
      • Heidari M.R.
      • Norouzadeh R.
      Supporting families of dying patients in the intensive care units.
      • Hibbert M.
      Stressors experienced by nurses while caring for organ donors and their families.
      • Holm M.S.
      • Fålun N.
      • Gjengedal E.
      • Norekvål T.M.
      Music during after-death care: a focus group study.
      • Kirchhoff K.T.
      • Spuhler V.
      • Walker L.
      • Hutton A.
      Intensive care nurses' experiences with end-of-life care.
      • Kisorio L.C.
      • Langley G.C.
      Intensive care nurses' experiences of end-of-life care.
      • McClement S.E.
      • Degner L.F.
      Expert nursing behaviors in care of the dying adult in the intensive care unit.
      • McMeekin D.E.
      • Hickman Jr., R.L.
      • Douglas S.L.
      • Kelley C.G.
      Stress and coping of critical care nurses after unsuccessful cardiopulmonary resuscitation.
      • Omran T.
      • Callis A.M.B.
      Bereavement needs of critical care nurses: a qualitative study.
      • Ong K.K.
      • Ting K.C.
      • Chow Y.L.
      The trajectory of experience of critical care nurses in providing end-of-life care: a qualitative descriptive study.
      • Pelletier-Hibbert M.
      Coping strategies used by nurses to deal with the care of organ donors and their families.
      • Rafii F.
      • Nikbakht Nasrabadi A.
      • Karim M.A.
      End-of-life care provision: experiences of intensive care nurses in Iraq.
      • Ranse K.
      • Yates P.
      • Coyer F.
      End-of-life care in the intensive care setting: a descriptive exploratory qualitative study of nurses' beliefs and practices.
      • Shorter M.
      • Stayt L.C.
      Critical care nurses' experiences of grief in an adult intensive care unit.
      • Taylor I.H.F.
      • Dihle A.
      • Hofsø K.
      • Steindal S.A.
      Intensive care nurses' experiences of withdrawal of life-sustaining treatments in intensive care patients: a qualitative study.
      • Velarde-García J.F.
      • Luengo-González R.
      • González-Hervias R.
      • Cardenete-Reyes C.
      • Alvarado-Zambrano G.
      • Palacios-Ceña D.
      Facing death in the intensive care unit. A phenomenological study of nurses' experiences.
      • Wu T.W.
      • Oliffe J.L.
      • Bungay V.
      • Johnson J.L.
      Male ICU nurses' experiences of taking care of dying patients and their families: a gender analysis.
      five were quantitative,
      • Attia A.K.
      • Abd-Elaziz W.W.
      • Kandeel N.A.
      Critical care nurses' perception of barriers and supportive behaviors in end-of-life care.
      • Egerod I.
      • Kaldan G.
      • Albarran J.
      • Coombs M.
      • Mitchell M.
      • Latour J.M.
      Elements of intensive care bereavement follow-up services: a European survey.
      • Egerod I.
      • Kaldan G.
      • Coombs M.
      • Mitchell M.
      Family-centered bereavement practices in Danish intensive care units: a cross-sectional national survey.
      • Riegel M.
      • Randall S.
      • Ranse K.
      • Buckley T.
      Healthcare professionals' values about and experience with facilitating end-of-life care in the adult intensive care unit.
      • Valks K.
      • Mitchell M.L.
      • Inglis-Simons C.
      • Limpus A.
      Dealing with death: an audit of family bereavement programs in Australian intensive care units.
      and the remaining two were mixed-method studies.
      • Kalocsai C.
      • des Ordons A.R.
      • Sinuff T.
      • Koo E.
      • Smith O.
      • Cook D.
      • et al.
      Critical care providers' support of families in bereavement: a mixed-methods study.
      ,
      • Spencer L.
      How do nurses deal with their own grief when a patient dies on an intensive care unit, and what help can be given to enable them to overcome their grief effectively?.
      Seven studies were conducted in Canada;
      • Bone N.
      • Swinton M.
      • Hoad N.
      • Toledo F.
      • Cook D.
      Critical care nurses' experiences with spiritual care: the SPIRIT study.
      ,
      • Gélinas C.
      • Fillion L.
      • Robitaille M.-A.
      • Truchon M.
      Stressors experienced by nurses providing end-of-life palliative care in the intensive care unit.
      ,
      • Hibbert M.
      Stressors experienced by nurses while caring for organ donors and their families.
      ,
      • McClement S.E.
      • Degner L.F.
      Expert nursing behaviors in care of the dying adult in the intensive care unit.
      ,
      • Pelletier-Hibbert M.
      Coping strategies used by nurses to deal with the care of organ donors and their families.
      ,
      • Wu T.W.
      • Oliffe J.L.
      • Bungay V.
      • Johnson J.L.
      Male ICU nurses' experiences of taking care of dying patients and their families: a gender analysis.
      ,
      • Kalocsai C.
      • des Ordons A.R.
      • Sinuff T.
      • Koo E.
      • Smith O.
      • Cook D.
      • et al.
      Critical care providers' support of families in bereavement: a mixed-methods study.
      four in Australia;
      • Bloomer M.J.
      • Morphet J.
      • O'Connor M.
      • Lee S.
      • Griffiths D.
      Nursing care of the family before and after a death in the ICU—an exploratory pilot study.
      ,
      • Halcomb E.
      • Daly J.
      • Jackson D.
      • Davidson P.
      An insight into Australian nurses' experience of withdrawal/withholding of treatment in the ICU.
      ,
      • Ranse K.
      • Yates P.
      • Coyer F.
      End-of-life care in the intensive care setting: a descriptive exploratory qualitative study of nurses' beliefs and practices.
      ,
      • Valks K.
      • Mitchell M.L.
      • Inglis-Simons C.
      • Limpus A.
      Dealing with death: an audit of family bereavement programs in Australian intensive care units.
      four in the United States of America (USA);
      • Hall M.A.
      Critical care registered nurses' preparedness in the provision of end-of-life care.
      ,
      • Kirchhoff K.T.
      • Spuhler V.
      • Walker L.
      • Hutton A.
      Intensive care nurses' experiences with end-of-life care.
      ,
      • McMeekin D.E.
      • Hickman Jr., R.L.
      • Douglas S.L.
      • Kelley C.G.
      Stress and coping of critical care nurses after unsuccessful cardiopulmonary resuscitation.
      ,
      • Omran T.
      • Callis A.M.B.
      Bereavement needs of critical care nurses: a qualitative study.
      three in the United Kingdom;
      • Stayt L.C.
      Death, empathy and self preservation: the emotional labour of caring for families of the critically ill in adult intensive care.
      ,
      • Shorter M.
      • Stayt L.C.
      Critical care nurses' experiences of grief in an adult intensive care unit.
      ,
      • Spencer L.
      How do nurses deal with their own grief when a patient dies on an intensive care unit, and what help can be given to enable them to overcome their grief effectively?.
      two in Norway,
      • Holm M.S.
      • Fålun N.
      • Gjengedal E.
      • Norekvål T.M.
      Music during after-death care: a focus group study.
      ,
      • Taylor I.H.F.
      • Dihle A.
      • Hofsø K.
      • Steindal S.A.
      Intensive care nurses' experiences of withdrawal of life-sustaining treatments in intensive care patients: a qualitative study.
      South Africa,
      • de Swardt C.
      • Fouché N.
      “What happens behind the curtains?” an exploration of ICU nurses' experiences of post mortem care on patients who have died in intensive care.
      ,
      • Kisorio L.C.
      • Langley G.C.
      Intensive care nurses' experiences of end-of-life care.
      and Turkey;
      • Çelik S.
      • Ugras G.A.
      • Durdu S.
      • Kubas M.
      • Aksoy G.
      Critical care nurses' knowledge about the care of deceased adult patients in an intensive care unit.
      ,
      • Çelik S.
      • Gürkan S.
      • Atlgan Y.
      A brief report of research: care activities for deceased atients of intensive care nurses at a private hospital in Istanbul, Turkey.
      one each in Denmark,
      • Egerod I.
      • Kaldan G.
      • Coombs M.
      • Mitchell M.
      Family-centered bereavement practices in Danish intensive care units: a cross-sectional national survey.
      Egypt,
      • Attia A.K.
      • Abd-Elaziz W.W.
      • Kandeel N.A.
      Critical care nurses' perception of barriers and supportive behaviors in end-of-life care.
      England,
      • Spencer L.
      How do nurses deal with their own grief when a patient dies on an intensive care unit, and what help can be given to enable them to overcome their grief effectively?.
      Europe,
      • Egerod I.
      • Kaldan G.
      • Albarran J.
      • Coombs M.
      • Mitchell M.
      • Latour J.M.
      Elements of intensive care bereavement follow-up services: a European survey.
      Indonesia,
      • Betriana F.
      • Kongsuwan W.
      Grief reactions and coping strategies of Muslim nurses dealing with death.
      Iran,
      • Heidari M.R.
      • Norouzadeh R.
      Supporting families of dying patients in the intensive care units.
      Kurdistan,
      • Rafii F.
      • Nikbakht Nasrabadi A.
      • Karim M.A.
      End-of-life care provision: experiences of intensive care nurses in Iraq.
      New Zealand,
      • Andrew C.M.
      Optimizing the human experience: nursing the families of people who die in intensive care.
      Singapore,
      • Ong K.K.
      • Ting K.C.
      • Chow Y.L.
      The trajectory of experience of critical care nurses in providing end-of-life care: a qualitative descriptive study.
      Spain,
      • Velarde-García J.F.
      • Luengo-González R.
      • González-Hervias R.
      • Cardenete-Reyes C.
      • Alvarado-Zambrano G.
      • Palacios-Ceña D.
      Facing death in the intensive care unit. A phenomenological study of nurses' experiences.
      and Sweden;
      • Forsberg A.
      • Flodén A.
      • Lennerling A.
      • Karlsson V.
      • Nilsson M.
      • Fridh I.
      The core of after death care in relation to organ donation–A grounded theory study.
      and one study across Europe and the Middle East (Table 3).
      • Benbenishty J.
      • Bennun M.
      • Lind R.
      Qualitative analysis of European and Middle East intensive care unit nursing death rituals.
      Three of the included studies focused on organ donation.
      • Forsberg A.
      • Flodén A.
      • Lennerling A.
      • Karlsson V.
      • Nilsson M.
      • Fridh I.
      The core of after death care in relation to organ donation–A grounded theory study.
      ,
      • Hibbert M.
      Stressors experienced by nurses while caring for organ donors and their families.
      ,
      • Pelletier-Hibbert M.
      Coping strategies used by nurses to deal with the care of organ donors and their families.
      Two papers report findings from the one study.
      • Hibbert M.
      Stressors experienced by nurses while caring for organ donors and their families.
      ,
      • Pelletier-Hibbert M.
      Coping strategies used by nurses to deal with the care of organ donors and their families.
      Collectively, the included studies represent the voices and perspectives of 1687 nurses. Quality appraisal scores for the included studies ranged from 4 to 11 (maximum score: 11) (Table 4). There was some variation in methodological quality of the 36 papers; most papers articulated a clear aim and purpose and reported an appropriate methodology. Potential ethical issues, including as an overt description of ethical priorities in research, such as minimising the risk of coercion and protecting participants' anonymity, were not identified or addressed in several papers,
      • Benbenishty J.
      • Bennun M.
      • Lind R.
      Qualitative analysis of European and Middle East intensive care unit nursing death rituals.
      ,
      • de Swardt C.
      • Fouché N.
      “What happens behind the curtains?” an exploration of ICU nurses' experiences of post mortem care on patients who have died in intensive care.
      ,
      • Gélinas C.
      • Fillion L.
      • Robitaille M.-A.
      • Truchon M.
      Stressors experienced by nurses providing end-of-life palliative care in the intensive care unit.
      ,
      • Hall M.A.
      Critical care registered nurses' preparedness in the provision of end-of-life care.
      ,
      • Heidari M.R.
      • Norouzadeh R.
      Supporting families of dying patients in the intensive care units.
      ,
      • Holm M.S.
      • Fålun N.
      • Gjengedal E.
      • Norekvål T.M.
      Music during after-death care: a focus group study.
      ,
      • Kirchhoff K.T.
      • Spuhler V.
      • Walker L.
      • Hutton A.
      Intensive care nurses' experiences with end-of-life care.
      ,
      • McMeekin D.E.
      • Hickman Jr., R.L.
      • Douglas S.L.
      • Kelley C.G.
      Stress and coping of critical care nurses after unsuccessful cardiopulmonary resuscitation.
      ,
      • Ranse K.
      • Yates P.
      • Coyer F.
      End-of-life care in the intensive care setting: a descriptive exploratory qualitative study of nurses' beliefs and practices.
      ,
      • Shorter M.
      • Stayt L.C.
      Critical care nurses' experiences of grief in an adult intensive care unit.
      ,
      • Attia A.K.
      • Abd-Elaziz W.W.
      • Kandeel N.A.
      Critical care nurses' perception of barriers and supportive behaviors in end-of-life care.
      ,
      • Egerod I.
      • Kaldan G.
      • Coombs M.
      • Mitchell M.
      Family-centered bereavement practices in Danish intensive care units: a cross-sectional national survey.
      • Riegel M.
      • Randall S.
      • Ranse K.
      • Buckley T.
      Healthcare professionals' values about and experience with facilitating end-of-life care in the adult intensive care unit.
      • Valks K.
      • Mitchell M.L.
      • Inglis-Simons C.
      • Limpus A.
      Dealing with death: an audit of family bereavement programs in Australian intensive care units.
      • Kalocsai C.
      • des Ordons A.R.
      • Sinuff T.
      • Koo E.
      • Smith O.
      • Cook D.
      • et al.
      Critical care providers' support of families in bereavement: a mixed-methods study.
      ,
      • Çelik S.
      • Gürkan S.
      • Atlgan Y.
      A brief report of research: care activities for deceased atients of intensive care nurses at a private hospital in Istanbul, Turkey.
      a finding potentially attributed to the brevity of writing and journal word limits for publications. Findings were synthesised into three categories: postmortem care, supporting bereaved families, and nurse coping with patient death. These categories represented nurses’ experiences after patient death in adult critical care (Fig. 2).
      Table 3Summary of included papers (n = 36).
      Authors, year of publicationCountry, setting & contextAim and/or research question/sSample & sample sizeMethodology & methodPrimary outcome
      Andrew 1998New Zealand. Two ICUs in a major teaching hospitalTo explain the phenomenon of optimising the human experience when nursing the families of people who die in the ICURegistered nurses (N = 7)Phenomenology; individual interviewThree domains are described that contribute to optimising the human experience. These were (i) nurse as person, (ii) nurse as practitioner and (iii) nurse as colleague. These three domains are enabled by a) being there, b) sharing, c) supporting, d) involving, e) interpreting, and f) advocating.
      Attia et al. 2013Egypt. Four ICUs:- (i) Oncology ICU; (ii) Coronary Care Unit; (iii) Hepatic ICU; and (iv) Surgical ICUTo assess nurses' perceptions of barriers and supportive behaviours in providing EOL care to dying patients and their families in ICUCritical care nurses (N = 70)Descriptive quantitative; structured interview using a previously published tool, translated into ArabicPerceptions of barriers to providing EOL care according to five categories (i) environmental barriers, (ii) family barriers, (iii) nurses' knowledge and skills, (iv) physicians' attitudes, and (v) treatment policy barriers. Top supportive behaviours for providing EOL care were (i) nurses' support, (ii) patient & family-centred care, (iii) families' support after patient's death. ICU type was associated with the level of barriers to providing EOL care. No association between critical care nurse characteristics and level of barriers.
      Benbenishty et al. 2020Europe and the Middle East (16 countries); ICUsTo describe European and Middle Eastern nursing ceremonies and rituals surrounding care provided to patients after deathCritical care nurses (N = 23)Qualitative study; face-to-face interviewsTwo main themes and five sub-themes were reported. (i) Sacredness includes (a) caring practice rituals and (b) care for the dying and deceased. (ii) Dignity includes (c) support for relatives and (d) effectiveness in contrast to dignified care.
      Betriana et al. 2020Indonesia; ICU in a public hospitalTo describe the grief reactions and coping strategies of Muslim nurses in dealing with the death of patientsRegistered nurses (N = 14)Qualitative phenomenological study; individual interviewsFour grief reactions: crying, feeling sad, disappointed & feeling guilt. Four factors influencing grief: circumstances of the patients, nurses' expectation, relationship with the patient, reaction to patient's family. Three coping strategies: sharing with colleagues, avoiding the dying & circumstances of death, & relying on spiritual strength
      Bloomer et al. 2013Australia. Two ICUs from two hospitals in metropolitan Melbourne, Australia: (i) 14 bed medical/surgical combined ICU and HDU; and (ii) 21 bed general medical/surgical ICU and HDU(i) To describe the way nurses ICU care for family members through the patient's dying and after death; (ii) To explore nurses' perspectives on their preparedness & ability to provide care for the family; (iii) to identify organisational processes & environmental factors that may exist in the ICU, that either facilitate or limit this nursing careRegistered nurses (N = 12)Qualitative exploratory descriptive study; Two focus group interviewsFour main themes emerged from the focus group data that represented the ways by which nurses endeavoured to ensure the experience of families was of as good a death as possible in the ICU environment, and the constraints on these roles. These themes included Time, Place, Presence and Culture.
      Bone et al. 2018Canada. 21 bed medical-surgical ICU in a teaching hospitalTo explore the effect of spiritual care on nurses and how nurses understand the role of spiritual careRegistered nurses (N = 25)Qualitative descriptive study; semistructured interviewsCentral theme that emerged was ‘presence’, described through three main categories: (i) present in the ICU and their role, (ii) nurses' experiences working with chaplains, (iii) nurses' experiences providing spiritual care
      Celik et al. 2008Turkey. Adult neurosurgery, coronary, cardiovascular, surgical, post-anaesthesia and emergency surgery ICUs in IstanbulTo determine ICU nurses' knowledge about activities for patients after they have diedRegistered nurses (N = 61)Quantitative descriptive study; self-administered questionnaireThe majority of nurses stated they removed instruments catheters, tubes, dressings from the body and cleaned drainage and secretions, but only 8.1% reported they dressed the patient in a clean gown and combed their hair. 24.5% did not provide emotional support to the individual's family.
      Celik et al. 2009Turkey. Cardiovascular surgical and surgical ICUs in IstanbulTo determine nursing care activities for deceased patients in the ICU. Research Questions: 1. What does a nurse do to care for deceased patients in the ICU? 2. What are the factors that influence nursing care activities for the deceased patient?Intensive care nurses (N = 20)Prospective, observational study, surveyDescriptions of post-mortem care were provided. There was no statistical difference in post-mortem care activities according to nurse characteristics. Nurses provided an environment suitable for families to say goodbye, but few described allowing families to participate in care
      de Swardt et al. 2017South Africa. A hospital from a consortium of private healthcare institutions in Cape TownQuestion: How do we better understand ICU nurses' experiences of performing post mortem care on patients who have died in an intensive care unit?ICU nurses (N = 6)Qualitative research; (i) semistructured interview, (ii) participant questionnaire and (iii) reflective journalingSafeguarding the integrity and physical appearance of the dead body was the major finding and of the utmost priority for the nurses in this study. Regardless of how the nurses felt about death, providing professional and quality care to the dead body and the family was seen as significantly important. The nurses, whilst performing post-mortem care, experienced detachment from various relationships. This comprised of the nurse detaching him/herself professionally and emotionally from the dead patient, the family and him/herself from the death experience. This ‘unspoken’ experience of thanatophobia became apparent when the nurses were confronted by the reality of their own deaths. Three main themes: (i) care of the dead body, (ii) detachment, (iii) thanatophobia
      Egerod, Kaldan, Albarran et al. 2019Europe. 48 cities in 18 European countries.To explore elements, organisation, and evaluation of ICU bereavement services in European countries. Objectives were to investigate (i) the model of bereavement follow-up services (elements of support), (ii) the workforce model (organisation of staff), and (iii) the evaluation model (evaluation strategies)Registered nurses (N = 85)Survey; sross-sectional self-administered, paper and pen surveyBereavement follow up existed for between 1 and 15 years.

      Important follow up elements were viewing the deceased in the unit, providing follow up information, sending a letter of sympathy, calling the family to arrange a meeting.
      Egerod, Kaldan, Coombs & Mitchell 2018Denmark. 48 ICUs(i) To gain an overview of interventions offered to family of deceased patients in ICUs; to describe characteristics of bereavement support; and (iii) to identify the role of ICU staff participating in these servicesRegistered nurses (N = 46)Survey; self-administered computerised cross-sectional nation-wide surveyBereavement care at the time of patient death included viewing the patient in ICU and in the hospital mortuary. Information about hospital-based follow-up for the family was provided in 72% of units, whereas only one unit provided information on community-based bereavement follow-up. Bereavement follow-up services after hospitalization were offered to families in 59% of ICUs and included an ICU visit, meeting with the staff present at the time of death, a letter of condolence, a phone call to the family, referral to a priest or clergy-man, or referral to other counselling.
      Forsberg et al. 2014Sweden; ICUTo investigate how intensive and critical care nurses experience and deal with after death care i.e. the period from notification of a possible brain dead person, and thereby possible organ donor, to the time of post-mortem farewellCritical care nurses (N = 29)Grounded theory; open-ended interviewsThe core category was ‘achieving a basis for organ donation through dignified and respectful care of the deceased person and the close relatives. Four main areas: (i) safeguarding the dignity of the deceased person, (ii) respecting the relatives, (iii) dignified and respectful care, and (iv) enabling a dignified farewell
      Gelinas et al. 2012Canada. Variety of hospitals in Quebec in terms of location (rural or urban), organisation (presence of intensivists and a palliative care team, and status (teaching or non-teaching)To better understand the stressors experienced by nurses providing EOL or palliative care in Canadian ICUs; To describe the stressors related to the provision of EOL or palliative care from the perspective of nurses in different settings in the province of QuebecRegistered nurses (N = 42)Descriptive qualitative design; focus groupsStressors clustered according to three categories: organisational, professional and emotional. Organisational stressors were a lack of palliative care approach, interprofessional difficulty, lack of continuity in life-support and treatment plans, and conflicting demands. Professional stressors were lack of EOL/PC competencies and difficulty communicating with families and collaborating with the medical team. Emotional stressors were described as value conflicts, lack of emotional support, and dealing with patient and family suffering
      Halcomb et al. 2004Australia. General ICUsTo investigate the experiences of nurses caring for clients in the ICU having treatment withdrawn or withheldRegistered nurses (N = 10)Phenomenology; conversational interviewsFive major themes emerged from the data (i) comfort and care, (ii) tension and conflict, (iii) do no harm, (iv) nurse-family relationships, and (v) invisibility of grief and suffering
      Hall et al. 2020USA. Critical Care Units or Intensive Care Units in the mid-Atlantic and west coast regionsQuestion: What are critical care registered nurses' perceptions of preparedness in the provision of EOL care?Critical care registered nurses (N = 14)Qualitative interpretive descriptionTo be prepared to provide EOL care, the nurses need to understand their personal beliefs about death and dying, be able to provide care to both patient and family, combine knowledge based on education, personal and professional experience, and support measures balance the ongoing dialogue between their professional and personal role as a registered nurse, and find ways to make sense of the dying experience, specifically through closure
      Heidari et al. 2014IranTo determine the Iranian nurses' experience of supporting families in EOL care(Not specified)Grounded theory; semistructured interviewsFamily support, dividing into 5 categories: death with dignity, facilitate visitation, value orientation, preparing, and distress
      Two papers representing one study.
      Hibbert 1995
      Canada. Neurological ICUs in two hospitals in eastern CanadaTo identify nurses' appraisal of stressors associated with providing care to organ donors and their families during the organ donation processRegistered nurses (N = 17)Retrospective, exploratory, descriptive study; individual semistructured interviewsThe threat of patient dying, the inconsistent commitment of physicians to organ donation, and returning to an empty space were frequently mentioned stressors. All nurses felt positive about being involved in the organ donation process
      Holm et al. 2012Norway. One ICU in a 1400-bed university hospital(i) to explore the experiences and attitudes of nurses towards the use of music played during after-death care and (ii) to describe the feedback nurses received from relatives when music was used as part of the viewingRegistered nurses (N = 15)Qualitative study; focus groupsSix main categories of attitudes emerged from the analysis: (i) different attitudes among nurses towards the use of music, (ii music affects the atmosphere, (iii) music affects emotions, (iv) use of music was situational, (v) special choice of music and (vi) positive feedback from the bereaved
      Kalocsai et al. 2020Canada. Nine adult medical-surgical ICUs within a university-affiliated hospital in Ontario and AlbertaTo explore how clinicians support bereaved families, identify factors that facilitate and hinder support and understand their interest and needs for follow-up.Nurses (N = 290) and physicians (N = 42)Mixed-methods exploratory study; interviews & surveysBoth physicians and nurses perceived that they provided empathetic support to bereaved families. Emotional engagement was a crucial element of support, but clinicians were not always able to engage with families
      Kirchhoff et al. 2000USA. 8 ICUs at 2 teaching hospitals in the intermountain WestTo describe EOL care in the ICU as perceived by critical care nurses who have taken care of dying patients.

      Research questions: (i) What do ICU nurses consider “good” EOL care? (ii) How do nurses describe their experiences of shifting from curative nursing interventions to EOL care? and (iii) What are ICU nurses' perceptions of care dilemmas and barriers to providing quality EOL care?
      Registered nurses (N = 21)Cross-sectional descriptive design; focus group (semistructured interview guide) and questionnaire"Good” EOL care in the ICU was described as ensuring that the patient is as pain-free as possible and that the patient's comfort and dignity are maintained. Involvement of the patient's family is critical. A clear, accurate prognosis and continuity of care also are important. Switching from curative to comfort care is awkward.
      Kisorio et al. 2016South Africa. General (medical-surgical), trauma and cardiothoracic ICUs at three academic affiliated tertiary (referral) hospitals in Johannesburg and Pretoria regionsTo explore South African intensive care nurses' experiences of EOL care in order to provide a basis for the development of interventions and support systems in the provision of quality EOL careICU nurses; (N = 24)Exploratory, descriptive qualitative design; focus groups and semistructured interviewsFive major themes related to nurses' experiences of EOL care included: difficulties we experience, discussion and decision making, support for patients, support for families and support for nurses.
      McClement et al. 1995Canada. Tertiary centre ICUs in community based hospitalTo identify expert nursing behaviours in care of the dying adult in the ICUICU nurses; (N = 10)Descriptive exploratoryBehaviours identified included: responding after death has occurred; responding to the family; responding to anger; responding to colleagues; providing comfort care; and enhancing personal growth
      McMeekin 2017USA. Subscribers to American Association of Critical Care Nurses weekly eNewsline, or followers of Facebook or TwitterTo explore the relationships among post-code stress, coping behaviours, and PTSD symptom severity in critical care nurses after experiencing unsuccessful cardiopulmonary resuscitations.Critical care nurses (N = 490)Descriptive correlational study; electronic surveyPostcode stress and PTSD symptom severity were weakly associated (r = 0.20, P = .01). No significant associations between coping behaviours and postcode stress were found. Four coping behaviours (denial, self-distraction, self-blame, and behavioural disengagement) were significant predictors of PTSD symptom severity. Severity of postcode stress and PTSD symptoms varied with the availability of institutional support.
      Omran 2021USA; Setting specifics not providedTo explore the lived experience of critical care nurses who are on the frontlines, managing critically ill patients who may be at EOL or experience sudden death. Questions:- (i) What are the bereavement needs of critical care nurses after experiencing the death of a patient? and (ii) From their lived experiences, how do nurses perceive how they process and cope with the death of a patient?Critical care nurses (N = 10)Qualitative, phenomenological study; focus groupResults: Seven themes emerged: (a) emotional distress, leading to compassion fatigue, burnout, and moral distress, (b) empathy, (c) resurfacing personal loss leading to secondary traumatic stress in the workplace, (d) unrealistic expectations placed on the nurse, (e) detachment leading to compartmentalization, (f) lack of formal education, and (g) self-care and available resources.
      Ong 2018Singapore. 20-bed medical ICUTo explore the perceptions of critical care nurses in Singapore towards providing EOL careRegistered nurses (N = 10)Qualitative, descriptive research using interviewsFour themes including (1) culture of care; (2) tension, (3) meaning of life and death, and (4) coming to terms
      Two papers representing one study.
      Pelletier-Hibbert 1998
      Canada. Neurological ICUs in two hospitals in eastern CanadaTo identify the different types and numbers of coping strategies used by nurses who care for organ donors and their familiesRegistered nurses (N = 17)Qualitative study; face-to-face interviewThe coping strategies that were used changed in number and type as the 3 stages of the organ donation process unfolded (anticipation, confrontation, pre-confrontation). Six major categories of coping strategies: exercising control, distancing, maintaining normality, seeking emotional support, taking time- out, and positive reappraisal
      Rafii et al. 2016Kurdistan. ICUs in Erbil CityTo explore the meaning of caring for terminally ill patients from the perspective of Kurdish ICU nursesRegistered nurses (N = 10)Hermeneutic phenomenology; interviewsFour major themes including emotional labour, death as a positive dimension, optimistic rather than futile care and working within constraints.
      Ranse et al. 2012Australia. 14-bed ICU at an Australian tertiary hospitalTo explore the EOL care beliefs and practices of intensive care nursesRegistered nurses (N = 5)Descriptive exploratory; interviewsThree major categories emerged from analysis of the interviews: beliefs about EOL care, EOL care in the ICU context and facilitating EOL care.
      Riegel et al. 2021Australia. 13-bed general ICU, 4-bed HDU at a tertiary referral centre in SydneyTo explore, through survey, provisions of EOL care for ICU healthcare professionalsRegistered nurses (N = 75), medical practitioners (N = 19) and social workers (N = 2)Cross-sectional study design: survey (paper and online)Compared to registered nurses, medical practitioners reported lower emotional and instrumental support after a death, including colleagues asking if OK, lower availability of counselling services, perceived insufficient time to spend with families, less in-service education for end-of-life topics and symptom management. Registered nurses reported lower scores related to knowing what to say to the family in end-of-life care scenarios
      Shorter et al. 2010United Kingdom. ICU of a large teaching hospitalTo explore critical care nurses' experiences of grief and their coping mechanisms when a patient diesRegistered nurses (sample size not reported)Heideggarian phenomenology; semistructured interviewsThemes: The death experience, incorporating expectedness, Control and good nursing care, Striking a chord and meaningful engagement, The death thereafter including formal and informal support, Normalization of death and Emotional Dissociation
      Spencer et al. 1994England. ICU in the north of England(i) How do nurses deal with their grief at present, following the death of a patient in an ICU? (ii) Is any support given to nurses by their peer group? (iii) Is any support given to nurses by their managers to help them overcome their grief? (iv) Do nurses feel that more information about how to deal with their grief, given during their training, would have been helpful? (v) Is more support wanted by nurses, in what form would they find it most beneficial?Trained nurses. Questionnaire (N = 72) and interview (N = 10)Mixed-method; questionnaire and semistructured interviewsThe qualitative data “shows how nurses deal with their grief, and that many, but not all, felt that the informal support network already present was sufficient. Some nurses, however, felt that a support group would also be helpful and some felt the availability of a counsellor would be useful. All nurses felt that more training about how to deal with their own grief was needed.
      Stayt 2009United Kingdom. Seven-bed ICU of a large teaching hospitalTo explore the emotional labour nurses face when caring for relatives of the critically ill in the ICURegistered nurses (N = 12)Heideggarian phenomenology; In-depth open-ended interviewsThemes: Significance of death, establishing trust, information giving, empathy, intimacy and self-preservation
      Taylor et al. 2020Norway. Four different adult ICUs (general, surgical, medical and trauma)To explore the experiences of ICU nurses when participating in withdrawal of life-sustaining treatmentICU nurses (N = 9)Qualitative descriptive and exploratory design; interviewsThree categories are described: (1) ICU nurses' experiences of stress in the process of treatment withdrawal; (2) a requirement for interdisciplinary support and cooperation; and (3) elements to achieve a dignified treatment withdrawal process.
      Valks et al. 2005Australia. Adult ICUsTo describe the bereavement services currently provided within general ICUs in AustraliaSenior nurses (N = 99)Survey; hard copy questionnaireIt was identified that most surveyed units offer minimal components of bereavement programs, such as viewing of the deceased and communicating with family members. Less than one third (n = 26) provide additional follow-up services in the form of telephone calls and sympathy cards or referral to additional services. Ten units employ some form of program evaluation. Verbal feedback from staff and families is the primary assessment method. Over half of responding ICUs indicated they are considering or interested in providing a bereavement program in their unit.
      Velarde-Garcia et al. 2016Spain. Post-reanimation, general, cardiac postsurgical, and cardiac ICUs within a University Hospital in Madrid;To describe the lived experiences of Spanish nurses working in ICUs regarding how they face the death of their patients.Nurses (N = 22)Qualitative phenomenology; individual unstructured or semistructured interviewsThree themes were identified: 1) dealing with expectations of recovery, 2) accepting the age of death, and 3) experiencing emotional attachment.
      Wu et al. 2015Canada. Two British Colombian ICUs at urban care hospitalsTo describe the connections between masculinities and male ICU nurses' experiences of caring for dying patients and their familiesICU nurses (N = 15)Interpretive descriptive interviewsThe thematic findings - (a) ensuring a dignified death, (b) changing the focus from patient to family, and (c) being emotionally attached, though interconnected
      EOL, end of life; HDU, high-dependency unit; ICU, intensive care unit.
      a Two papers representing one study.
      Table 4Quality appraisal.
      Author/s, yearQuality appraisal (out of 11)Critical appraisal comments
      Andrew, 19988Title and content not consistent. Tool not tested.
      Attia et al., 20138#Potential ethical issues not identified or addressed.
      Benbenishty et al., 20209Details of ethical approval not clear. Methodological detail missing, such as recruitment, interview length, and transcription.
      Betriana et al., 202011
      Bloomer et al., 201311
      Bone et al., 20187No detail of ethical approval. Rationale for method not provided. No recommendations for further research or implications for practice.
      Celik et al., 20084Incongruence between aim and focus of questionnaire. Tool not tested. Limited detail about survey or analysis. Inconsistent detail re nurse sample. Conclusion brief.
      Celik et al., 20096Abstract does not describe the full scope of findings. Literature review is brief. #Potential ethical issues not identified or addressed. Methodology not justified.
      de Swardt et al., 20178#Potential ethical issues not identified or addressed.
      Egerod et al., 20199Conclusion is brief.
      Egerod et al., 201810Sparse detail re ethical issues.
      Forsberg et al., 201410Minimal references to literature in Introduction
      Gelinas et al., 20128#Potential ethical issues not identified or addressed.
      Halcomb et al., 200411
      Hall, 20209Rationale for study not clearly outlined. #Potential ethical issues not identified or addressed.
      Heidari et al., 20147Methodology not justified. #Potential ethical issues not adequately identified or addressed. No recommendations for future research or practice.
      Two papers reported findings from the one study.#
      Hibbert, 1995
      8Aim not specifically stated. No specific con
      Holm et al., 201210#Potential ethical issues not identified or addressed.
      Kalocsai et al., 202010#Potential ethical issues not identified or addressed.
      Kirchhoff et al., 20009#Potential ethical issues not identified or addressed. Conclusion is brief.
      Kisorio et al., 201610Method brief and not justified
      McClement et al., 19959Literature review is brief. #Potential ethical issues not identified or addressed.
      McMeekin 20179#Potential ethical issues not identified or addressed. Discussion is brief.
      Omran 20219Method and discussion brief and lacking detail.
      Ong 201810Study rationale not provided.
      Two papers reported findings from the one study.#
      Pelletier-Hibbert 1998
      8Literature review brief. No evidence of ethical approval. Methodology not justified.
      Rafii et al., 201611
      Ranse et al., 201210#Potential ethical issues not identified or addressed.
      Riegel et al., 202110#Potential ethical issues not identified or addressed.
      Shorter et al., 202010#Potential ethical issues not identified or addressed.
      Spencer, 19949#Potential ethical issues not identified or addressed. Conclusion brief.
      Stayt, 200911
      Taylor et al., 202010Discussion not comprehensive.
      Valks et al., 20058Aim not clearly stated. #Potential ethical issues not identified or addressed. Discussion not comprehensive
      Velarde-Garcia et al., 201610Methodology not justified.
      Wu et al., 201511
      a Two papers reported findings from the one study.#

      3.1 Postmortem care

      A total of five studies described postmortem care of the deceased.
      • Benbenishty J.
      • Bennun M.
      • Lind R.
      Qualitative analysis of European and Middle East intensive care unit nursing death rituals.
      ,
      • Çelik S.
      • Ugras G.A.
      • Durdu S.
      • Kubas M.
      • Aksoy G.
      Critical care nurses' knowledge about the care of deceased adult patients in an intensive care unit.
      • de Swardt C.
      • Fouché N.
      “What happens behind the curtains?” an exploration of ICU nurses' experiences of post mortem care on patients who have died in intensive care.
      • Forsberg A.
      • Flodén A.
      • Lennerling A.
      • Karlsson V.
      • Nilsson M.
      • Fridh I.
      The core of after death care in relation to organ donation–A grounded theory study.
      ,
      • Holm M.S.
      • Fålun N.
      • Gjengedal E.
      • Norekvål T.M.
      Music during after-death care: a focus group study.
      Postmortem care encompassed demonstrating respect and dignity for the deceased, preparation of the deceased, and the concurrent death rituals performed by nurses.

      3.1.1 Demonstrating respect and dignity

      Demonstrating respect and dignity for the deceased was detailed in six studies.
      • Benbenishty J.
      • Bennun M.
      • Lind R.
      Qualitative analysis of European and Middle East intensive care unit nursing death rituals.
      ,
      • de Swardt C.
      • Fouché N.
      “What happens behind the curtains?” an exploration of ICU nurses' experiences of post mortem care on patients who have died in intensive care.
      ,
      • Forsberg A.
      • Flodén A.
      • Lennerling A.
      • Karlsson V.
      • Nilsson M.
      • Fridh I.
      The core of after death care in relation to organ donation–A grounded theory study.
      ,
      • Heidari M.R.
      • Norouzadeh R.
      Supporting families of dying patients in the intensive care units.
      ,
      • Holm M.S.
      • Fålun N.
      • Gjengedal E.
      • Norekvål T.M.
      Music during after-death care: a focus group study.
      ,
      • McClement S.E.
      • Degner L.F.
      Expert nursing behaviors in care of the dying adult in the intensive care unit.
      Nurses reported providing care that mimicked the respectful care provided to living patients
      • Benbenishty J.
      • Bennun M.
      • Lind R.
      Qualitative analysis of European and Middle East intensive care unit nursing death rituals.
      ,
      • McClement S.E.
      • Degner L.F.
      Expert nursing behaviors in care of the dying adult in the intensive care unit.
      and talking to the deceased to “… bid him farewell, wishing him a safe journey … telling him he did good in this world”.
      • Benbenishty J.
      • Bennun M.
      • Lind R.
      Qualitative analysis of European and Middle East intensive care unit nursing death rituals.
      “Although there is no life you must care for your patient in many ways; psychologically, physically, emotionally …. Although there is no life there is still the body and those parts [nursing care] you still have to go through”.
      • de Swardt C.
      • Fouché N.
      “What happens behind the curtains?” an exploration of ICU nurses' experiences of post mortem care on patients who have died in intensive care.
      Respect for the deceased was also demonstrated by handling the body “in a correct way
      • de Swardt C.
      • Fouché N.
      “What happens behind the curtains?” an exploration of ICU nurses' experiences of post mortem care on patients who have died in intensive care.
      such as taking care with turning as if the deceased could have felt pain.
      • Benbenishty J.
      • Bennun M.
      • Lind R.
      Qualitative analysis of European and Middle East intensive care unit nursing death rituals.
      There was a desire to make the deceased “look like they did before” by removing lines
      • McClement S.E.
      • Degner L.F.
      Expert nursing behaviors in care of the dying adult in the intensive care unit.
      and covering the body.
      • Heidari M.R.
      • Norouzadeh R.
      Supporting families of dying patients in the intensive care units.
      Other nurses controlled the immediate environment using subdued lighting, modulating noise,
      • McClement S.E.
      • Degner L.F.
      Expert nursing behaviors in care of the dying adult in the intensive care unit.
      and speaking in low voices.
      • Benbenishty J.
      • Bennun M.
      • Lind R.
      Qualitative analysis of European and Middle East intensive care unit nursing death rituals.
      Music was described as being able to bring “some more solemnity … and a little dignity …”.
      • Holm M.S.
      • Fålun N.
      • Gjengedal E.
      • Norekvål T.M.
      Music during after-death care: a focus group study.
      Music also had negative connotations, with a nurse describing how she advocated for a respectful and dignified environment during postmortem care for an organ donor, by asking that music be turned off:“Sometimes you have to go to radiology for an angiography. Every now and then they have a commercial radio on through speakers in the room. You have perhaps been working with your patient for a whole afternoon or perhaps been comforting the relatives and you hear that overpowering music and you ask them to turn that radio off, but they have no idea what it’s all about”.
      • Forsberg A.
      • Flodén A.
      • Lennerling A.
      • Karlsson V.
      • Nilsson M.
      • Fridh I.
      The core of after death care in relation to organ donation–A grounded theory study.

      3.1.2 Preparation of the deceased

      Preparation of the deceased was described in four studies and encompassed practical aspects of preparing the body so that the family could say goodbye.
      • Benbenishty J.
      • Bennun M.
      • Lind R.
      Qualitative analysis of European and Middle East intensive care unit nursing death rituals.
      ,
      • Çelik S.
      • Ugras G.A.
      • Durdu S.
      • Kubas M.
      • Aksoy G.
      Critical care nurses' knowledge about the care of deceased adult patients in an intensive care unit.
      ,
      • de Swardt C.
      • Fouché N.
      “What happens behind the curtains?” an exploration of ICU nurses' experiences of post mortem care on patients who have died in intensive care.
      ,
      • Çelik S.
      • Gürkan S.
      • Atlgan Y.
      A brief report of research: care activities for deceased atients of intensive care nurses at a private hospital in Istanbul, Turkey.
      In two studies, nurses expressed a lack of clarity in what postmortem care entailed,
      • Çelik S.
      • Ugras G.A.
      • Durdu S.
      • Kubas M.
      • Aksoy G.
      Critical care nurses' knowledge about the care of deceased adult patients in an intensive care unit.
      ,
      • de Swardt C.
      • Fouché N.
      “What happens behind the curtains?” an exploration of ICU nurses' experiences of post mortem care on patients who have died in intensive care.
      such as “How do I know that I am doing the ‘right thing’?”
      • de Swardt C.
      • Fouché N.
      “What happens behind the curtains?” an exploration of ICU nurses' experiences of post mortem care on patients who have died in intensive care.
      yet in another, a standard protocol was available to guide care of the deceased.
      • Çelik S.
      • Gürkan S.
      • Atlgan Y.
      A brief report of research: care activities for deceased atients of intensive care nurses at a private hospital in Istanbul, Turkey.
      Preparation of the deceased was also described in one study as a task to “get over and done with”.
      • Benbenishty J.
      • Bennun M.
      • Lind R.
      Qualitative analysis of European and Middle East intensive care unit nursing death rituals.
      In three studies, family members had the option to be present when the body was prepared.
      • Benbenishty J.
      • Bennun M.
      • Lind R.
      Qualitative analysis of European and Middle East intensive care unit nursing death rituals.
      ,
      • Çelik S.
      • Ugras G.A.
      • Durdu S.
      • Kubas M.
      • Aksoy G.
      Critical care nurses' knowledge about the care of deceased adult patients in an intensive care unit.
      ,
      • Çelik S.
      • Gürkan S.
      • Atlgan Y.
      A brief report of research: care activities for deceased atients of intensive care nurses at a private hospital in Istanbul, Turkey.
      Postmortem care was considered easier and more comfortable when two nurses performed this care together.
      • de Swardt C.
      • Fouché N.
      “What happens behind the curtains?” an exploration of ICU nurses' experiences of post mortem care on patients who have died in intensive care.
      Preparation of the deceased included separating the deceased patient from all others by closing the curtain or using a screen,
      • Çelik S.
      • Gürkan S.
      • Atlgan Y.
      A brief report of research: care activities for deceased atients of intensive care nurses at a private hospital in Istanbul, Turkey.
      removal of tubes and lines and washing the body,
      • Benbenishty J.
      • Bennun M.
      • Lind R.
      Qualitative analysis of European and Middle East intensive care unit nursing death rituals.
      ,
      • Çelik S.
      • Ugras G.A.
      • Durdu S.
      • Kubas M.
      • Aksoy G.
      Critical care nurses' knowledge about the care of deceased adult patients in an intensive care unit.
      ,
      • de Swardt C.
      • Fouché N.
      “What happens behind the curtains?” an exploration of ICU nurses' experiences of post mortem care on patients who have died in intensive care.
      ,
      • Çelik S.
      • Gürkan S.
      • Atlgan Y.
      A brief report of research: care activities for deceased atients of intensive care nurses at a private hospital in Istanbul, Turkey.
      closing the eyes, dressing wounds, combing the deceased's hair, shaving male patients, inserting dentures, dressing the deceased in a clean gown, placing a rolled towel under the chin,
      • Çelik S.
      • Ugras G.A.
      • Durdu S.
      • Kubas M.
      • Aksoy G.
      Critical care nurses' knowledge about the care of deceased adult patients in an intensive care unit.
      ,
      • Çelik S.
      • Gürkan S.
      • Atlgan Y.
      A brief report of research: care activities for deceased atients of intensive care nurses at a private hospital in Istanbul, Turkey.
      and placing clean sheets on the bed.
      • Benbenishty J.
      • Bennun M.
      • Lind R.
      Qualitative analysis of European and Middle East intensive care unit nursing death rituals.
      ,
      • Çelik S.
      • Ugras G.A.
      • Durdu S.
      • Kubas M.
      • Aksoy G.
      Critical care nurses' knowledge about the care of deceased adult patients in an intensive care unit.
      Nurses described laying the deceased flat, with arms straight
      • Çelik S.
      • Ugras G.A.
      • Durdu S.
      • Kubas M.
      • Aksoy G.
      Critical care nurses' knowledge about the care of deceased adult patients in an intensive care unit.
      ,
      • de Swardt C.
      • Fouché N.
      “What happens behind the curtains?” an exploration of ICU nurses' experiences of post mortem care on patients who have died in intensive care.
      so that “… the patient looks comfortable …”.
      • de Swardt C.
      • Fouché N.
      “What happens behind the curtains?” an exploration of ICU nurses' experiences of post mortem care on patients who have died in intensive care.
      The surroundings were prepared by removing excess equipment, the room was cleaned, and chairs were arranged
      • de Swardt C.
      • Fouché N.
      “What happens behind the curtains?” an exploration of ICU nurses' experiences of post mortem care on patients who have died in intensive care.
      so that family members could say goodbye.
      • Çelik S.
      • Ugras G.A.
      • Durdu S.
      • Kubas M.
      • Aksoy G.
      Critical care nurses' knowledge about the care of deceased adult patients in an intensive care unit.
      ,
      • Çelik S.
      • Gürkan S.
      • Atlgan Y.
      A brief report of research: care activities for deceased atients of intensive care nurses at a private hospital in Istanbul, Turkey.
      Prior to sending the deceased to the mortuary, the body was wrapped in a sheet or shroud, labelled and/or tagged with identifying details, and the death documented as required.
      • Çelik S.
      • Ugras G.A.
      • Durdu S.
      • Kubas M.
      • Aksoy G.
      Critical care nurses' knowledge about the care of deceased adult patients in an intensive care unit.

      3.1.3 Death rituals

      Death rituals were important for acknowledging and respecting cultural and religious needs of the deceased and the nurse and were founded on nursing tradition passed down through the generations
      • Benbenishty J.
      • Bennun M.
      • Lind R.
      Qualitative analysis of European and Middle East intensive care unit nursing death rituals.
      ,
      • de Swardt C.
      • Fouché N.
      “What happens behind the curtains?” an exploration of ICU nurses' experiences of post mortem care on patients who have died in intensive care.
      ,
      • Holm M.S.
      • Fålun N.
      • Gjengedal E.
      • Norekvål T.M.
      Music during after-death care: a focus group study.
      : “… it is my responsibility to pass this ritual art of nursing practice on to the next generation of nurses”.
      • Benbenishty J.
      • Bennun M.
      • Lind R.
      Qualitative analysis of European and Middle East intensive care unit nursing death rituals.
      Typically performed synonymously with postmortem care,
      • Benbenishty J.
      • Bennun M.
      • Lind R.
      Qualitative analysis of European and Middle East intensive care unit nursing death rituals.
      ,
      • Çelik S.
      • Ugras G.A.
      • Durdu S.
      • Kubas M.
      • Aksoy G.
      Critical care nurses' knowledge about the care of deceased adult patients in an intensive care unit.
      ,
      • de Swardt C.
      • Fouché N.
      “What happens behind the curtains?” an exploration of ICU nurses' experiences of post mortem care on patients who have died in intensive care.
      ,
      • Holm M.S.
      • Fålun N.
      • Gjengedal E.
      • Norekvål T.M.
      Music during after-death care: a focus group study.
      death rituals were considered important to honouring the death “… and legitimised it [death] as an honour in respect and as a farewell”,
      • Benbenishty J.
      • Bennun M.
      • Lind R.
      Qualitative analysis of European and Middle East intensive care unit nursing death rituals.
      but the ritual was seldom shared with family. Although nurses believed their rituals were personal and unique, there were similarities across participants, countries, and religions.
      • Benbenishty J.
      • Bennun M.
      • Lind R.
      Qualitative analysis of European and Middle East intensive care unit nursing death rituals.
      A participant from a Middle Eastern context described the use of a cart containing artefacts for use during after-death care, such as the Bible, the Koran, amulet beads, holy water, a book of hymns and prayers, and a head covering for the deceased.
      • Benbenishty J.
      • Bennun M.
      • Lind R.
      Qualitative analysis of European and Middle East intensive care unit nursing death rituals.
      Others described how they chose to play music during postmortem care because music made “… the feeling stronger about what we are really doing” and enhanced “… a feeling of peace”;
      • Holm M.S.
      • Fålun N.
      • Gjengedal E.
      • Norekvål T.M.
      Music during after-death care: a focus group study.
      yet for others, there was a preference for quiet.
      • Holm M.S.
      • Fålun N.
      • Gjengedal E.
      • Norekvål T.M.
      Music during after-death care: a focus group study.
      The use of a clean sheet to cover the body was described as signifying the purity of death,
      • de Swardt C.
      • Fouché N.
      “What happens behind the curtains?” an exploration of ICU nurses' experiences of post mortem care on patients who have died in intensive care.
      and opening a window allowed the deceased's soul to fly or escape to “the other side”.
      • Benbenishty J.
      • Bennun M.
      • Lind R.
      Qualitative analysis of European and Middle East intensive care unit nursing death rituals.
      Nurses described holding the deceased patient's hand,
      • Çelik S.
      • Ugras G.A.
      • Durdu S.
      • Kubas M.
      • Aksoy G.
      Critical care nurses' knowledge about the care of deceased adult patients in an intensive care unit.
      crossing themselves or the deceased person's body, or both, or blessing the body by touching the forehead or chest.
      • Benbenishty J.
      • Bennun M.
      • Lind R.
      Qualitative analysis of European and Middle East intensive care unit nursing death rituals.
      Prayers and/hymns were used as part of a blessing,
      • Benbenishty J.
      • Bennun M.
      • Lind R.
      Qualitative analysis of European and Middle East intensive care unit nursing death rituals.
      sometimes shared with family because “The soul is going to God now and we have to pray and let them go”.
      • de Swardt C.
      • Fouché N.
      “What happens behind the curtains?” an exploration of ICU nurses' experiences of post mortem care on patients who have died in intensive care.
      Respecting religion was seen as a sign of respect for the patient and family, acknowledging that “It just depends on the religion of the patient that passed away”.
      • de Swardt C.
      • Fouché N.
      “What happens behind the curtains?” an exploration of ICU nurses' experiences of post mortem care on patients who have died in intensive care.

      3.2 Supporting bereaved families

      Eighteen studies provided data on the provision of immediate grief and bereavement support after death of the patient, and across time.
      • Bloomer M.J.
      • Morphet J.
      • O'Connor M.
      • Lee S.
      • Griffiths D.
      Nursing care of the family before and after a death in the ICU—an exploratory pilot study.
      ,
      • Andrew C.M.
      Optimizing the human experience: nursing the families of people who die in intensive care.
      ,
      • Benbenishty J.
      • Bennun M.
      • Lind R.
      Qualitative analysis of European and Middle East intensive care unit nursing death rituals.
      ,
      • Bone N.
      • Swinton M.
      • Hoad N.
      • Toledo F.
      • Cook D.
      Critical care nurses' experiences with spiritual care: the SPIRIT study.
      ,
      • Çelik S.
      • Ugras G.A.
      • Durdu S.
      • Kubas M.
      • Aksoy G.
      Critical care nurses' knowledge about the care of deceased adult patients in an intensive care unit.
      ,
      • Forsberg A.
      • Flodén A.
      • Lennerling A.
      • Karlsson V.
      • Nilsson M.
      • Fridh I.
      The core of after death care in relation to organ donation–A grounded theory study.
      ,
      • Hibbert M.
      Stressors experienced by nurses while caring for organ donors and their families.
      ,
      • Kirchhoff K.T.
      • Spuhler V.
      • Walker L.
      • Hutton A.
      Intensive care nurses' experiences with end-of-life care.
      ,
      • McClement S.E.
      • Degner L.F.
      Expert nursing behaviors in care of the dying adult in the intensive care unit.
      ,
      • Omran T.
      • Callis A.M.B.
      Bereavement needs of critical care nurses: a qualitative study.
      ,
      • Ranse K.
      • Yates P.
      • Coyer F.
      End-of-life care in the intensive care setting: a descriptive exploratory qualitative study of nurses' beliefs and practices.
      ,
      • Taylor I.H.F.
      • Dihle A.
      • Hofsø K.
      • Steindal S.A.
      Intensive care nurses' experiences of withdrawal of life-sustaining treatments in intensive care patients: a qualitative study.
      ,
      • Egerod I.
      • Kaldan G.
      • Albarran J.
      • Coombs M.
      • Mitchell M.
      • Latour J.M.
      Elements of intensive care bereavement follow-up services: a European survey.
      • Egerod I.
      • Kaldan G.
      • Coombs M.
      • Mitchell M.
      Family-centered bereavement practices in Danish intensive care units: a cross-sectional national survey.
      • Riegel M.
      • Randall S.
      • Ranse K.
      • Buckley T.
      Healthcare professionals' values about and experience with facilitating end-of-life care in the adult intensive care unit.
      • Valks K.
      • Mitchell M.L.
      • Inglis-Simons C.
      • Limpus A.
      Dealing with death: an audit of family bereavement programs in Australian intensive care units.
      • Kalocsai C.
      • des Ordons A.R.
      • Sinuff T.
      • Koo E.
      • Smith O.
      • Cook D.
      • et al.
      Critical care providers' support of families in bereavement: a mixed-methods study.
      ,
      • Çelik S.
      • Gürkan S.
      • Atlgan Y.
      A brief report of research: care activities for deceased atients of intensive care nurses at a private hospital in Istanbul, Turkey.
      Importantly, not all nurses were comfortable supporting bereaved families
      • Kalocsai C.
      • des Ordons A.R.
      • Sinuff T.
      • Koo E.
      • Smith O.
      • Cook D.
      • et al.
      Critical care providers' support of families in bereavement: a mixed-methods study.
      or felt adequately prepared or skilled: “They just look petrified … they just can't wait to get out … they don't know the answers … and they're probably confronted by it”.
      • Bloomer M.J.
      • Morphet J.
      • O'Connor M.
      • Lee S.
      • Griffiths D.
      Nursing care of the family before and after a death in the ICU—an exploratory pilot study.
      As a result, nurses were often allocated to dying patients because they demonstrated the right qualities:“There are certain nurses … they’re always allocated to those patients ‘cause [because] they’ve got a track record of being communicators … empathetic, caring, listening, they can listen to relatives … and they know what to say … you can’t be taught those things”.
      • Bloomer M.J.
      • Morphet J.
      • O'Connor M.
      • Lee S.
      • Griffiths D.
      Nursing care of the family before and after a death in the ICU—an exploratory pilot study.
      Supporting bereaved families was thought to be based on a desire to reach out to other human beings facing difficult times, in a profoundly human way.
      • Andrew C.M.
      Optimizing the human experience: nursing the families of people who die in intensive care.
      Demonstrating empathy
      • Omran T.
      • Callis A.M.B.
      Bereavement needs of critical care nurses: a qualitative study.
      ,
      • Taylor I.H.F.
      • Dihle A.
      • Hofsø K.
      • Steindal S.A.
      Intensive care nurses' experiences of withdrawal of life-sustaining treatments in intensive care patients: a qualitative study.
      and caring through displays of emotion were also described and linked to the importance of acknowledging the death:
      • McClement S.E.
      • Degner L.F.
      Expert nursing behaviors in care of the dying adult in the intensive care unit.
      “You are not lessened in their eyes if you shed tears with them … it validates the family grief and loss”.
      • Kirchhoff K.T.
      • Spuhler V.
      • Walker L.
      • Hutton A.
      Intensive care nurses' experiences with end-of-life care.
      Knowing the family allowed some nurses to more holistically support them after death.
      • Bloomer M.J.
      • Morphet J.
      • O'Connor M.
      • Lee S.
      • Griffiths D.
      Nursing care of the family before and after a death in the ICU—an exploratory pilot study.
      Nurses described spending time at the bedside with the family
      • Bloomer M.J.
      • Morphet J.
      • O'Connor M.
      • Lee S.
      • Griffiths D.
      Nursing care of the family before and after a death in the ICU—an exploratory pilot study.
      and attempting to ensure family wishes were accommodated.
      • Taylor I.H.F.
      • Dihle A.
      • Hofsø K.
      • Steindal S.A.
      Intensive care nurses' experiences of withdrawal of life-sustaining treatments in intensive care patients: a qualitative study.
      Allowing families time to spend alone with the deceased was considered important.
      • Benbenishty J.
      • Bennun M.
      • Lind R.
      Qualitative analysis of European and Middle East intensive care unit nursing death rituals.
      ,
      • Çelik S.
      • Ugras G.A.
      • Durdu S.
      • Kubas M.
      • Aksoy G.
      Critical care nurses' knowledge about the care of deceased adult patients in an intensive care unit.
      ,
      • Taylor I.H.F.
      • Dihle A.
      • Hofsø K.
      • Steindal S.A.
      Intensive care nurses' experiences of withdrawal of life-sustaining treatments in intensive care patients: a qualitative study.
      ,
      • Riegel M.
      • Randall S.
      • Ranse K.
      • Buckley T.
      Healthcare professionals' values about and experience with facilitating end-of-life care in the adult intensive care unit.
      ,
      • Çelik S.
      • Gürkan S.
      • Atlgan Y.
      A brief report of research: care activities for deceased atients of intensive care nurses at a private hospital in Istanbul, Turkey.
      One nurse encouraged family to reduce potential future regret by talking to the deceased:“I always tell the family … if there's something that you need to say to them that hasn't been said, this is the time to do it. You never know what kind of burdens people are carrying with them, but at least they get a chance to say it, you know?”.
      • McClement S.E.
      • Degner L.F.
      Expert nursing behaviors in care of the dying adult in the intensive care unit.
      Several studies also detailed how nurses provided information to families of the deceased. The nurses' role was described as guiding families on the practicalities because “… a lot of families turn around and go ‘What do I do now, do we call the funeral home …”.
      • Bloomer M.J.
      • Morphet J.
      • O'Connor M.
      • Lee S.
      • Griffiths D.
      Nursing care of the family before and after a death in the ICU—an exploratory pilot study.
      Brochures and handouts were used to provide practical information on what families need to do
      • Benbenishty J.
      • Bennun M.
      • Lind R.
      Qualitative analysis of European and Middle East intensive care unit nursing death rituals.
      ,
      • Egerod I.
      • Kaldan G.
      • Albarran J.
      • Coombs M.
      • Mitchell M.
      • Latour J.M.
      Elements of intensive care bereavement follow-up services: a European survey.
      and sources of emotional and spiritual support such as the hospital chaplain or priest
      • Egerod I.
      • Kaldan G.
      • Albarran J.
      • Coombs M.
      • Mitchell M.
      • Latour J.M.
      Elements of intensive care bereavement follow-up services: a European survey.
      and external/community support services such as counselling.
      • Egerod I.
      • Kaldan G.
      • Coombs M.
      • Mitchell M.
      Family-centered bereavement practices in Danish intensive care units: a cross-sectional national survey.
      ,
      • Valks K.
      • Mitchell M.L.
      • Inglis-Simons C.
      • Limpus A.
      Dealing with death: an audit of family bereavement programs in Australian intensive care units.
      One study described how nurses used mementos to support family grieving, such as a hand print, a lock of the patient's hair, or the hospital identification band.
      • Ranse K.
      • Yates P.
      • Coyer F.
      End-of-life care in the intensive care setting: a descriptive exploratory qualitative study of nurses' beliefs and practices.
      Similarly, patient diaries compiled over the course of the patient's admission
      • Egerod I.
      • Kaldan G.
      • Albarran J.
      • Coombs M.
      • Mitchell M.
      • Latour J.M.
      Elements of intensive care bereavement follow-up services: a European survey.
      were provided to families in another study as keepsakes.
      Bereavement support for families could continue after the family leave the unit, but it was not a universal practice. Whilst some nurses reported their units did not offer any bereavement services,
      • Egerod I.
      • Kaldan G.
      • Albarran J.
      • Coombs M.
      • Mitchell M.
      • Latour J.M.
      Elements of intensive care bereavement follow-up services: a European survey.
      ,
      • Kalocsai C.
      • des Ordons A.R.
      • Sinuff T.
      • Koo E.
      • Smith O.
      • Cook D.
      • et al.
      Critical care providers' support of families in bereavement: a mixed-methods study.
      in other studies, bereavement support and follow-up included a telephone call, letter, or sympathy card sent to the family;
      • Egerod I.
      • Kaldan G.
      • Albarran J.
      • Coombs M.
      • Mitchell M.
      • Latour J.M.
      Elements of intensive care bereavement follow-up services: a European survey.
      ,
      • Egerod I.
      • Kaldan G.
      • Coombs M.
      • Mitchell M.
      Family-centered bereavement practices in Danish intensive care units: a cross-sectional national survey.
      ,
      • Valks K.
      • Mitchell M.L.
      • Inglis-Simons C.
      • Limpus A.
      Dealing with death: an audit of family bereavement programs in Australian intensive care units.
      an invitation to a follow-up meeting with member of the intensive care unit team;
      • Benbenishty J.
      • Bennun M.
      • Lind R.
      Qualitative analysis of European and Middle East intensive care unit nursing death rituals.
      ,
      • Egerod I.
      • Kaldan G.
      • Albarran J.
      • Coombs M.
      • Mitchell M.
      • Latour J.M.
      Elements of intensive care bereavement follow-up services: a European survey.
      and/or an invitation to read through a patient diary in person.
      • Egerod I.
      • Kaldan G.
      • Albarran J.
      • Coombs M.
      • Mitchell M.
      • Latour J.M.
      Elements of intensive care bereavement follow-up services: a European survey.

      3.2.1 Supporting families of potential organ donors

      When a patient was declared brain dead, the approach to bereavement support was distinctly different because care for the body continued, as described in two studies.
      • Forsberg A.
      • Flodén A.
      • Lennerling A.
      • Karlsson V.
      • Nilsson M.
      • Fridh I.
      The core of after death care in relation to organ donation–A grounded theory study.
      ,
      • Hibbert M.
      Stressors experienced by nurses while caring for organ donors and their families.
      A clear shift was described in how nurses talk to families “… to speaking about the person in the past tense”,
      • Forsberg A.
      • Flodén A.
      • Lennerling A.
      • Karlsson V.
      • Nilsson M.
      • Fridh I.
      The core of after death care in relation to organ donation–A grounded theory study.
      where the goal was to be sympathetic and respectful. In order to emphasise that the patient was dead, to aid families to come to terms with the diagnosis and the option of organ donation:“We usually start by asking the relative after the patient is diagnosed as brain dead if they have any idea what the patient thought about the idea of organ donation … I do not want to influence them one way or another because I'm afraid they may later regret their decision and will be unhappy about my behaviour. I want it to be their decision regardless of what they decide, my thoughts must never play any part in their decision making".
      • Forsberg A.
      • Flodén A.
      • Lennerling A.
      • Karlsson V.
      • Nilsson M.
      • Fridh I.
      The core of after death care in relation to organ donation–A grounded theory study.
      The focus of bereavement support was on guiding donor families through their shock and grief to a state of acceptance and hope, experiencing a sense of meaning in an otherwise devastating and senseless situation.
      • Forsberg A.
      • Flodén A.
      • Lennerling A.
      • Karlsson V.
      • Nilsson M.
      • Fridh I.
      The core of after death care in relation to organ donation–A grounded theory study.
      Postmortem close contact with families was maintained until the donor left the unit, and relatives were debriefed for a final time.
      • Forsberg A.
      • Flodén A.
      • Lennerling A.
      • Karlsson V.
      • Nilsson M.
      • Fridh I.
      The core of after death care in relation to organ donation–A grounded theory study.
      Nonetheless, there was a profound sense of helplessness in attempting to ease family members’ pain.
      • Hibbert M.
      Stressors experienced by nurses while caring for organ donors and their families.

      3.2.2 System pressures

      In four studies, system pressures impacted the support provided to bereaved families.
      • Bloomer M.J.
      • Morphet J.
      • O'Connor M.
      • Lee S.
      • Griffiths D.
      Nursing care of the family before and after a death in the ICU—an exploratory pilot study.
      ,
      • Kisorio L.C.
      • Langley G.C.
      Intensive care nurses' experiences of end-of-life care.
      ,
      • McClement S.E.
      • Degner L.F.
      Expert nursing behaviors in care of the dying adult in the intensive care unit.
      ,
      • Kalocsai C.
      • des Ordons A.R.
      • Sinuff T.
      • Koo E.
      • Smith O.
      • Cook D.
      • et al.
      Critical care providers' support of families in bereavement: a mixed-methods study.
      The time and workload associated with helping and supporting families after a patient death was not recognised,
      • Bloomer M.J.
      • Morphet J.
      • O'Connor M.
      • Lee S.
      • Griffiths D.
      Nursing care of the family before and after a death in the ICU—an exploratory pilot study.
      nor was the importance of ensuring families were able to spend time with the body. In three studies, nurses reported pressure to hasten the process or remove the deceased so that the bed space could be utilised for another patient.
      • Bloomer M.J.
      • Morphet J.
      • O'Connor M.
      • Lee S.
      • Griffiths D.
      Nursing care of the family before and after a death in the ICU—an exploratory pilot study.
      ,
      • McClement S.E.
      • Degner L.F.
      Expert nursing behaviors in care of the dying adult in the intensive care unit.
      ,
      • Kalocsai C.
      • des Ordons A.R.
      • Sinuff T.
      • Koo E.
      • Smith O.
      • Cook D.
      • et al.
      Critical care providers' support of families in bereavement: a mixed-methods study.
      A nurse described what occurred as she supported a son to grieve at his deceased father's bedside:“… we had an admission in emergency waiting to come into that bed. Everyone was getting annoyed with me because I was letting this fellow stay so long. One nurse suggested that I just call security. That made me really angry. I suppose I was being very indulgent but his father had just died, when shouldn't you be indulgent?”.
      • McClement S.E.
      • Degner L.F.
      Expert nursing behaviors in care of the dying adult in the intensive care unit.
      A lack of support from social workers and pastoral care outside of normal business hours was raised as a concern, as demonstrated in this example about the spouse of an older patient who had died overnight:“… Wife passes away and then [the husband] goes ‘I don’t know what to do now? I’ve no idea what to do from here on, what happens?’ starts crying … being a weekend no social worker was available. [I call the] on-call social worker and she goes ‘I’m not very sure if I should come in or should I just talk to him over the phone?… I’m not very sure if he needs me I think he should just google those things up on the internet and I’m pretty sure that he will be able to find something’”.
      • Bloomer M.J.
      • Morphet J.
      • O'Connor M.
      • Lee S.
      • Griffiths D.
      Nursing care of the family before and after a death in the ICU—an exploratory pilot study.

      3.3 Nurse coping with patient death

      Nurses’ emotional response to patient death and coping strategies were described in almost all the included studies, synonymous with the caring relationship and a sense of connection. Coping mechanisms included formal and informal supports, normalising death, and recognising the fragility of life and strategies for self-care.

      3.3.1 Emotional response to patient death

      Sixteen studies described nurses' emotional response to patient death.
      • Stayt L.C.
      Death, empathy and self preservation: the emotional labour of caring for families of the critically ill in adult intensive care.
      ,
      • Bloomer M.J.
      • Morphet J.
      • O'Connor M.
      • Lee S.
      • Griffiths D.
      Nursing care of the family before and after a death in the ICU—an exploratory pilot study.
      ,
      • Andrew C.M.
      Optimizing the human experience: nursing the families of people who die in intensive care.
      • Benbenishty J.
      • Bennun M.
      • Lind R.
      Qualitative analysis of European and Middle East intensive care unit nursing death rituals.
      • Betriana F.
      • Kongsuwan W.
      Grief reactions and coping strategies of Muslim nurses dealing with death.
      ,
      • Gélinas C.
      • Fillion L.
      • Robitaille M.-A.
      • Truchon M.
      Stressors experienced by nurses providing end-of-life palliative care in the intensive care unit.
      ,
      • Hibbert M.
      Stressors experienced by nurses while caring for organ donors and their families.
      ,
      • Kirchhoff K.T.
      • Spuhler V.
      • Walker L.
      • Hutton A.
      Intensive care nurses' experiences with end-of-life care.
      ,
      • Kisorio L.C.
      • Langley G.C.
      Intensive care nurses' experiences of end-of-life care.
      ,
      • McMeekin D.E.
      • Hickman Jr., R.L.
      • Douglas S.L.
      • Kelley C.G.
      Stress and coping of critical care nurses after unsuccessful cardiopulmonary resuscitation.
      • Omran T.
      • Callis A.M.B.
      Bereavement needs of critical care nurses: a qualitative study.
      • Ong K.K.
      • Ting K.C.
      • Chow Y.L.
      The trajectory of experience of critical care nurses in providing end-of-life care: a qualitative descriptive study.
      ,
      • Rafii F.
      • Nikbakht Nasrabadi A.
      • Karim M.A.
      End-of-life care provision: experiences of intensive care nurses in Iraq.
      ,
      • Shorter M.
      • Stayt L.C.
      Critical care nurses' experiences of grief in an adult intensive care unit.
      ,
      • Velarde-García J.F.
      • Luengo-González R.
      • González-Hervias R.
      • Cardenete-Reyes C.
      • Alvarado-Zambrano G.
      • Palacios-Ceña D.
      Facing death in the intensive care unit. A phenomenological study of nurses' experiences.
      ,
      • Spencer L.
      How do nurses deal with their own grief when a patient dies on an intensive care unit, and what help can be given to enable them to overcome their grief effectively?.
      In six studies, a strong sense of connection with the deceased patient's family influenced nurses' emotional responses.
      • Stayt L.C.
      Death, empathy and self preservation: the emotional labour of caring for families of the critically ill in adult intensive care.
      ,
      • Bloomer M.J.
      • Morphet J.
      • O'Connor M.
      • Lee S.
      • Griffiths D.
      Nursing care of the family before and after a death in the ICU—an exploratory pilot study.
      ,
      • Andrew C.M.
      Optimizing the human experience: nursing the families of people who die in intensive care.
      ,
      • Omran T.
      • Callis A.M.B.
      Bereavement needs of critical care nurses: a qualitative study.
      ,
      • Shorter M.
      • Stayt L.C.
      Critical care nurses' experiences of grief in an adult intensive care unit.
      ,
      • Velarde-García J.F.
      • Luengo-González R.
      • González-Hervias R.
      • Cardenete-Reyes C.
      • Alvarado-Zambrano G.
      • Palacios-Ceña D.
      Facing death in the intensive care unit. A phenomenological study of nurses' experiences.
      For example:I felt that I really shared in their painful experience … I felt really close to the family because I had been there since the moment he was admitted to the moment he died. I’d been there through it all and really felt as though I was going through it with them".
      • Stayt L.C.
      Death, empathy and self preservation: the emotional labour of caring for families of the critically ill in adult intensive care.
      Connection was also attributed to sharing the patient's experience where “you really feel like you have been on that journey with them”.
      • Shorter M.
      • Stayt L.C.
      Critical care nurses' experiences of grief in an adult intensive care unit.
      Identifying with patient characteristics such as age or their personal history, being able to communicate with the patient prior to their deterioration and death,
      • Shorter M.
      • Stayt L.C.
      Critical care nurses' experiences of grief in an adult intensive care unit.
      ,
      • Velarde-García J.F.
      • Luengo-González R.
      • González-Hervias R.
      • Cardenete-Reyes C.
      • Alvarado-Zambrano G.
      • Palacios-Ceña D.
      Facing death in the intensive care unit. A phenomenological study of nurses' experiences.
      and building rapport with the family also impacted a nurse's response to patient death.
      • Andrew C.M.
      Optimizing the human experience: nursing the families of people who die in intensive care.
      ,
      • Omran T.
      • Callis A.M.B.
      Bereavement needs of critical care nurses: a qualitative study.
      Whilst these studies suggest an openness to connecting with families, in doing so “you are exposing yourself to the relatives, it's a vulnerable situation”.
      • Bloomer M.J.
      • Morphet J.
      • O'Connor M.
      • Lee S.
      • Griffiths D.
      Nursing care of the family before and after a death in the ICU—an exploratory pilot study.
      One nurse explained “ … I would like to put a barrier there, for a little self-defence, but it is very difficult …”.
      • Velarde-García J.F.
      • Luengo-González R.
      • González-Hervias R.
      • Cardenete-Reyes C.
      • Alvarado-Zambrano G.
      • Palacios-Ceña D.
      Facing death in the intensive care unit. A phenomenological study of nurses' experiences.
      Feelings such as sadness, anger, guilt, shock, and relief
      • Spencer L.
      How do nurses deal with their own grief when a patient dies on an intensive care unit, and what help can be given to enable them to overcome their grief effectively?.
      and terms such as “used to it” and “desensitized” demonstrated the scope of nurses' emotional responses.
      • Ong K.K.
      • Ting K.C.
      • Chow Y.L.
      The trajectory of experience of critical care nurses in providing end-of-life care: a qualitative descriptive study.
      If the nurse knew the family intimately, if the nurse had spent a lot of time talking with the family,
      • Spencer L.
      How do nurses deal with their own grief when a patient dies on an intensive care unit, and what help can be given to enable them to overcome their grief effectively?.
      or if family were hopeful the patient would get better, the nurses’ emotional response to patient death was more intense.
      • Betriana F.
      • Kongsuwan W.
      Grief reactions and coping strategies of Muslim nurses dealing with death.
      Similarly, the death of a pregnant or recently postpartum woman
      • Betriana F.
      • Kongsuwan W.
      Grief reactions and coping strategies of Muslim nurses dealing with death.
      or a younger patient was thought to be more distressing
      • Betriana F.
      • Kongsuwan W.
      Grief reactions and coping strategies of Muslim nurses dealing with death.
      ,
      • McMeekin D.E.
      • Hickman Jr., R.L.
      • Douglas S.L.
      • Kelley C.G.
      Stress and coping of critical care nurses after unsuccessful cardiopulmonary resuscitation.
      : “… the young ones touch me as they still have a future”.
      • Kisorio L.C.
      • Langley G.C.
      Intensive care nurses' experiences of end-of-life care.
      Conversely, the death of an older patient was described as more acceptable and nurses were able to more readily rationalise the death as an inevitable and normal part of life,
      • Ong K.K.
      • Ting K.C.
      • Chow Y.L.
      The trajectory of experience of critical care nurses in providing end-of-life care: a qualitative descriptive study.
      as one nurse explained “ … in an elderly patient, death is more normal, it gives him rest, it is the law of life that an elderly patient must die”.
      • Velarde-García J.F.
      • Luengo-González R.
      • González-Hervias R.
      • Cardenete-Reyes C.
      • Alvarado-Zambrano G.
      • Palacios-Ceña D.
      Facing death in the intensive care unit. A phenomenological study of nurses' experiences.
      When the death was expected, the experience was thought to be less traumatic for nurses.
      • Shorter M.
      • Stayt L.C.
      Critical care nurses' experiences of grief in an adult intensive care unit.
      In the case of patients who were brain dead, who were potential organ donors, there was a sense of having “… failed the family”, and the time spent waiting for the deceased to be taken to theatre for organ retrieval was described as “unbearable”.
      • Hibbert M.
      Stressors experienced by nurses while caring for organ donors and their families.
      When a donor's organs could not be retrieved, there was a sense of disappointment and frustration because “neither the donor family or the patient waiting for an organ transplantation benefits … What a waste! … totally senseless”.
      • Hibbert M.
      Stressors experienced by nurses while caring for organ donors and their families.
      When families displayed a dramatic emotional response to patient death, this influenced nurses’ ability to cope with emotions.
      • Bloomer M.J.
      • Morphet J.
      • O'Connor M.
      • Lee S.
      • Griffiths D.
      Nursing care of the family before and after a death in the ICU—an exploratory pilot study.
      ,
      • Betriana F.
      • Kongsuwan W.
      Grief reactions and coping strategies of Muslim nurses dealing with death.
      ,
      • Ong K.K.
      • Ting K.C.
      • Chow Y.L.
      The trajectory of experience of critical care nurses in providing end-of-life care: a qualitative descriptive study.
      Patient death was also described as capable of eliciting a visceral response “When my patients die, my whole body is covered by sweat and I get paled …”.
      • Rafii F.
      • Nikbakht Nasrabadi A.
      • Karim M.A.
      End-of-life care provision: experiences of intensive care nurses in Iraq.
      Nurses in two studies felt responsible and experienced heightened emotions when they were present for the withdrawal of life support;
      • Gélinas C.
      • Fillion L.
      • Robitaille M.-A.
      • Truchon M.
      Stressors experienced by nurses providing end-of-life palliative care in the intensive care unit.
      ,
      • Spencer L.
      How do nurses deal with their own grief when a patient dies on an intensive care unit, and what help can be given to enable them to overcome their grief effectively?.
      “ … that burden, of the family standing around, looking at you … what they remember is that you made them die …”.
      • Gélinas C.
      • Fillion L.
      • Robitaille M.-A.
      • Truchon M.
      Stressors experienced by nurses providing end-of-life palliative care in the intensive care unit.

      3.3.2 Coping mechanisms

      The way in which nurses coped with patient death varied and was represented in 19 studies.
      • Benbenishty J.
      • Bennun M.
      • Lind R.
      Qualitative analysis of European and Middle East intensive care unit nursing death rituals.
      • Betriana F.
      • Kongsuwan W.
      Grief reactions and coping strategies of Muslim nurses dealing with death.
      • Bone N.
      • Swinton M.
      • Hoad N.
      • Toledo F.
      • Cook D.
      Critical care nurses' experiences with spiritual care: the SPIRIT study.
      ,
      • Halcomb E.
      • Daly J.
      • Jackson D.
      • Davidson P.
      An insight into Australian nurses' experience of withdrawal/withholding of treatment in the ICU.
      ,
      • Hall M.A.
      Critical care registered nurses' preparedness in the provision of end-of-life care.
      ,
      • Hibbert M.
      Stressors experienced by nurses while caring for organ donors and their families.
      ,
      • Kirchhoff K.T.
      • Spuhler V.
      • Walker L.
      • Hutton A.
      Intensive care nurses' experiences with end-of-life care.
      • Kisorio L.C.
      • Langley G.C.
      Intensive care nurses' experiences of end-of-life care.
      • McClement S.E.
      • Degner L.F.
      Expert nursing behaviors in care of the dying adult in the intensive care unit.
      • McMeekin D.E.
      • Hickman Jr., R.L.
      • Douglas S.L.
      • Kelley C.G.
      Stress and coping of critical care nurses after unsuccessful cardiopulmonary resuscitation.
      • Omran T.
      • Callis A.M.B.
      Bereavement needs of critical care nurses: a qualitative study.
      • Ong K.K.
      • Ting K.C.
      • Chow Y.L.
      The trajectory of experience of critical care nurses in providing end-of-life care: a qualitative descriptive study.
      • Pelletier-Hibbert M.
      Coping strategies used by nurses to deal with the care of organ donors and their families.
      ,
      • Ranse K.
      • Yates P.
      • Coyer F.
      End-of-life care in the intensive care setting: a descriptive exploratory qualitative study of nurses' beliefs and practices.
      ,
      • Shorter M.
      • Stayt L.C.
      Critical care nurses' experiences of grief in an adult intensive care unit.
      ,
      • Wu T.W.
      • Oliffe J.L.
      • Bungay V.
      • Johnson J.L.
      Male ICU nurses' experiences of taking care of dying patients and their families: a gender analysis.
      ,
      • Riegel M.
      • Randall S.
      • Ranse K.
      • Buckley T.
      Healthcare professionals' values about and experience with facilitating end-of-life care in the adult intensive care unit.
      ,
      • Kalocsai C.
      • des Ordons A.R.
      • Sinuff T.
      • Koo E.
      • Smith O.
      • Cook D.
      • et al.
      Critical care providers' support of families in bereavement: a mixed-methods study.
      ,
      • Spencer L.
      How do nurses deal with their own grief when a patient dies on an intensive care unit, and what help can be given to enable them to overcome their grief effectively?.
      In reflecting on coping, nurses reported that maintaining a focus on personal values irrespective of the outcome was shared
      • Kirchhoff K.T.
      • Spuhler V.
      • Walker L.
      • Hutton A.
      Intensive care nurses' experiences with end-of-life care.
      ; similarly, normalising death as a natural part of life
      • Shorter M.
      • Stayt L.C.
      Critical care nurses' experiences of grief in an adult intensive care unit.
      and realising that “… you have a job to do … so you kind of get used to that”
      • Hall M.A.
      Critical care registered nurses' preparedness in the provision of end-of-life care.
      helped. Focusing on the satisfaction that can come from helping and supporting a family,
      • Kirchhoff K.T.
      • Spuhler V.
      • Walker L.
      • Hutton A.
      Intensive care nurses' experiences with end-of-life care.
      helping family in their grief,
      • Wu T.W.
      • Oliffe J.L.
      • Bungay V.
      • Johnson J.L.
      Male ICU nurses' experiences of taking care of dying patients and their families: a gender analysis.
      contributing to a successful organ donation,
      • Pelletier-Hibbert M.
      Coping strategies used by nurses to deal with the care of organ donors and their families.
      and acknowledging the benefit of organ donation to others
      • Hibbert M.
      Stressors experienced by nurses while caring for organ donors and their families.
      were also described as ways of coping. Learning from their own past experiences and by watching other nurses helped in the development of coping skills.
      • Omran T.
      • Callis A.M.B.
      Bereavement needs of critical care nurses: a qualitative study.
      Whilst some nurses spoke of ‘leaving work at work’,
      • Pelletier-Hibbert M.
      Coping strategies used by nurses to deal with the care of organ donors and their families.
      findings from multiple studies suggested that support received from colleagues was what made this possible.
      • Benbenishty J.
      • Bennun M.
      • Lind R.
      Qualitative analysis of European and Middle East intensive care unit nursing death rituals.
      • Betriana F.
      • Kongsuwan W.
      Grief reactions and coping strategies of Muslim nurses dealing with death.
      • Bone N.
      • Swinton M.
      • Hoad N.
      • Toledo F.
      • Cook D.
      Critical care nurses' experiences with spiritual care: the SPIRIT study.
      ,
      • Gélinas C.
      • Fillion L.
      • Robitaille M.-A.
      • Truchon M.
      Stressors experienced by nurses providing end-of-life palliative care in the intensive care unit.
      ,
      • Kirchhoff K.T.
      • Spuhler V.
      • Walker L.
      • Hutton A.
      Intensive care nurses' experiences with end-of-life care.
      • Kisorio L.C.
      • Langley G.C.
      Intensive care nurses' experiences of end-of-life care.
      • McClement S.E.
      • Degner L.F.
      Expert nursing behaviors in care of the dying adult in the intensive care unit.
      ,
      • Omran T.
      • Callis A.M.B.
      Bereavement needs of critical care nurses: a qualitative study.
      ,
      • Ong K.K.
      • Ting K.C.
      • Chow Y.L.
      The trajectory of experience of critical care nurses in providing end-of-life care: a qualitative descriptive study.
      ,
      • Wu T.W.
      • Oliffe J.L.
      • Bungay V.
      • Johnson J.L.
      Male ICU nurses' experiences of taking care of dying patients and their families: a gender analysis.
      ,
      • Spencer L.
      How do nurses deal with their own grief when a patient dies on an intensive care unit, and what help can be given to enable them to overcome their grief effectively?.
      An emphasis on nurse-to-nurse relationships and the ‘team’ helped build camaraderie and led to nurses supporting each other
      • Shorter M.
      • Stayt L.C.
      Critical care nurses' experiences of grief in an adult intensive care unit.
      and checking in with each other at the right time.
      • Bone N.
      • Swinton M.
      • Hoad N.
      • Toledo F.
      • Cook D.
      Critical care nurses' experiences with spiritual care: the SPIRIT study.
      ,
      • McClement S.E.
      • Degner L.F.
      Expert nursing behaviors in care of the dying adult in the intensive care unit.
      ,
      • Omran T.
      • Callis A.M.B.
      Bereavement needs of critical care nurses: a qualitative study.
      Findings from a survey of critical care nurses in the UK indicated that just over 80% of nurses received support from colleagues in the form of informal discussions, mutual and moral support, and supportive listening,
      • Spencer L.
      How do nurses deal with their own grief when a patient dies on an intensive care unit, and what help can be given to enable them to overcome their grief effectively?.
      a finding also reflected across multiple statements in an Australian survey.
      • Riegel M.
      • Randall S.
      • Ranse K.
      • Buckley T.
      Healthcare professionals' values about and experience with facilitating end-of-life care in the adult intensive care unit.
      As one nurse explained:“The support you give each other, the other colleagues you work with, know exactly what you’re going through, so quite often an informal chat in the coffee room is just as therapeutic
      • Shorter M.
      • Stayt L.C.
      Critical care nurses' experiences of grief in an adult intensive care unit.
      Collegial support was also evident in awareness of who recently experienced a patient death and careful consideration when allocating care for the next dying patient.
      • Kisorio L.C.
      • Langley G.C.
      Intensive care nurses' experiences of end-of-life care.
      But not all nurses felt supported, with one describing her experience after death of a young pregnant patient: “No one said anything. It was like okay, let us get on with our daily lives. Who cares a 27-year-old just died?… I do not think there is like enough support”.
      • Hall M.A.
      Critical care registered nurses' preparedness in the provision of end-of-life care.
      More formal supports were described and included clinical supervision and formal debriefing. Whilst some nurses reported feeling as though they were just expected to cope with grief and dying,
      • Ranse K.
      • Yates P.
      • Coyer F.
      End-of-life care in the intensive care setting: a descriptive exploratory qualitative study of nurses' beliefs and practices.
      others expressed a desire for formal debriefing as a way to “… sit together and vent your feelings of fear, anger or frustration”
      • Pelletier-Hibbert M.
      Coping strategies used by nurses to deal with the care of organ donors and their families.
      and to be supported after a tough situation in a way that allowed participants in the debrief to discuss their particular struggles.
      • Taylor I.H.F.
      • Dihle A.
      • Hofsø K.
      • Steindal S.A.
      Intensive care nurses' experiences of withdrawal of life-sustaining treatments in intensive care patients: a qualitative study.
      Yet others felt that “if you make it a formal setting … by the pure nature of doing that, people [will] feel more inhibited”.
      • Shorter M.
      • Stayt L.C.
      Critical care nurses' experiences of grief in an adult intensive care unit.
      Nurses in one study felt counselling may help by providing an opportunity to talk with someone,
      • Kisorio L.C.
      • Langley G.C.
      Intensive care nurses' experiences of end-of-life care.
      but nurses in some studies reported counselling services were not readily available
      • Halcomb E.
      • Daly J.
      • Jackson D.
      • Davidson P.
      An insight into Australian nurses' experience of withdrawal/withholding of treatment in the ICU.
      ,
      • Riegel M.
      • Randall S.
      • Ranse K.
      • Buckley T.
      Healthcare professionals' values about and experience with facilitating end-of-life care in the adult intensive care unit.
      and that nurses did not want to use formal services.
      • Omran T.
      • Callis A.M.B.
      Bereavement needs of critical care nurses: a qualitative study.
      ,
      • Ranse K.
      • Yates P.
      • Coyer F.
      End-of-life care in the intensive care setting: a descriptive exploratory qualitative study of nurses' beliefs and practices.
      Outside of the critical care unit, strategies to aid coping included time alone to process the death,
      • Hibbert M.
      Stressors experienced by nurses while caring for organ donors and their families.
      ,
      • Pelletier-Hibbert M.
      Coping strategies used by nurses to deal with the care of organ donors and their families.
      reflect
      • Gélinas C.
      • Fillion L.
      • Robitaille M.-A.
      • Truchon M.
      Stressors experienced by nurses providing end-of-life palliative care in the intensive care unit.
      ,
      • Hall M.A.