UCSF

The purpose of this grounded theory study was to explore how nurses in acute care units and an end-of-life facility manage professional and personal boundaries while delivering palliative care to children and families. Pediatric palliative care principles emphasize providing emotional support to children with life-limiting illness and thier family members. Families desire this support during such a vulnerable and intimate experience. Nurses derive satisfaction and see their work as meaningful when they are able to engage and connect with patients and families, but patients' deaths also provoke feelings of grief and a sense of loss. This study asked, "What process(es) do nurses who work in pediatric palliative care use to negotiate boundaries?" It additionally explored how work settings and emotions affect this process.

A purposive sample of 18 registered nurses participated and they were recruited from two sites: a children's hospital and a free-standing end-of-life facility. Within the children's hospital, nurses were recruited from the hematology/oncology/ bone marrow transplant unit, the Pediatric Intensive Care Unit, and the Intensive Care Nursery. Participants were interviewed using a semi-structured interview guide and observed in their work setting. Data was analyzed using grounded theory and situational analysis methodologies.

Major findings centered on how nurses constructed, perceived, and negotiated boundaries. Findings indicated that the nature of participants' practice required them to actively navigate personal and professional boundaries in order to deliver competent and compassionate care. Although there were identified differences among settings, all participants shared a similar process, maintaining integrity, in navigating boundaries. Nurses worked within an external and internal context which influenced this process and subsequently shaped their nursing practice. Participants described a range of emotions and coping strategies which enabled them to continue practicing in a field which required a level of emotional engagement.

The findings contribute to better understanding of how to provide optimal palliative care to children and families. Nurses perceived boundaries as flexible, rather than rigid and they emanated from within nurses, rather than being externally imposed on them. Important practice implications suggest the need to strengthen professional support for nurses in pediatric palliative care through training, education, and ongoing emotional assessments.