Results from several research studies combined with increasing public tensions surrounding physician-assisted suicide have fueled a growing awareness of the inadequacies of end-of-life care. Investigators also suggest that intensive care unit nurses have a limited role in end-of-life decision making and care planning. This article explores cultural issues influencing end-of-life care in intensive care units, explores factors surrounding the limited involvement of critical care nurses in end-of-life decision making and care planning, and offers recommendations for changing nursing practice. Because improving end-of-life care will require cultural changes, an understanding of the cultural issues involved is needed. Recommendations for changing nursing practice include a model of end-of-life care that incorporates the goals of both cure and comfort care, as well as a shared decision-making process. Nurses are essential to improving end-of-life care in today's intensive care units.
BACKGROUND: Cyclical fluctuations in turnover of critical care nurses are a large and complex problem. Managers' leadership characteristics may be a determinant of critical care nurses' intent to stay in the job. OBJECTIVE: To examine the direct and indirect effects of nurse-managers' characteristics of power, influence, and leadership style on critical care nurses' intent to stay in the nurses' employment positions. METHODS: The sample was 255 staff nurses in intensive care units at 4 urban hospitals. Established instruments with sound reliability and validity were used to assess the predictor, intervening, and outcome variables. Path analysis was used to examine the relationships in a conceptual model of intent to stay. RESULTS: The model explained 52% of the variance in intent to stay, and managers' characteristics were significant at each stage. Managers' position power and influence over work coordination had a direct link to intent to stay; structuring expectations and consideration contributed indirectly through the variables of instrumental communication, autonomy, and group cohesion. Instrumental communication, autonomy, and group cohesion decreased job stress and thus increased job satisfaction. Job satisfaction was directly linked with intent to stay. CONCLUSIONS: Inclusion of nurse-managers' characteristics explained more variance in intent to stay than did previous models. Managers with leadership styles that seek and value contributions from staff, promote a climate in which information is shared effectively, promote decision making at the staff nurse level, exert position power, and influence coordination of work to provide a milieu that maintains a stable cadre of nurses.