Experiences of intensive care unit nurses in end-of-life care at Ho Teaching Hospital, Ghana: a qualitative study

Abstract

Background

Healthcare workers have an ethical obligation to provide quality end-of-life (EOL) care. Yet, substantial gaps persist in EOL practices globally and in Ghana specifically. Intensive care unit (ICU) nurses are pivotal in EOL care but frequently experience distress and unpreparedness when caring for dying patients. Ho Teaching Hospital, a major regional referral center in Ghana, has begun initial efforts to improve EOL care. However, systematic integration of EOL care principles is still lacking.

Aim

This study aims to explore the experiences of ICU nurses providing EOL care at the Ho Teaching Hospital in Ghana, to understand the specific needs and challenges faced by this facility, and to drive targeted improvements.

Methods

The study employed an exploratory qualitative design and a purposive sampling method to recruit 20 nurses working in the ICU of the Ho Teaching Hospital in Ghana. The study used semi-structured interviews to gather data from the nurses who had experience providing EOL care to patients. Data was analysed thematically using NVivo version 14.

Results

Key findings from the interviews with ICU nurses revealed some major challenges which included inadequate equipment, understaffing, excessive workloads, and managing family-related issues. Nurses described the work as extremely stressful and emotionally draining. They frequently encounter traditional practices by families that interfere with medical care. The nurses recommended improving resources and equipment, enhancing training and support for staff, implementing communication and education programs, and increasing staffing.

Conclusion

This study highlights the importance of improving intensive care nursing practices, including staffing, equipment availability, specialized training, and mental health support. These improvements can enhance care quality and nurse retention while also reducing burnout and emotional distress. Empowering frontline nurses and implementing evidence-based interventions can further improve care quality. The study recommends that policymakers should consider integrating EOL care modules into ICU nurses’ continuing professional development, establishing mandatory staff counselling programs, and prioritizing resource allocation to critical care units.

Background

Globally, more than 60 million people in low- and middle-income countries (LMICs) have no or extremely limited access to either palliative care services or essential palliative care medicines. Indeed, only 12% of the global palliative care needs are currently being met and only about 4% of Africans who need palliative end-of-life (EOL) services receive them [1]. According to the World Health Organization, 56.8 million people are estimated to need palliative care services each year; however, only 14% of these people receive them. Half of this estimated need for palliative care is reported among those living in Africa. Annually, 8 million patients in intensive care units (ICUs) pass away, with many undergoing intense treatments right up to death [2].

The limited access to palliative care services has been linked to barriers such as lack of national policies, opioid restrictions, workforce shortages, and inadequate EOL education among healthcare professionals [3]. While these systemic challenges in ICU EOL care exist worldwide, examining a specific local context can provide valuable insights into nurses’ experiences within healthcare settings and cultures [4].

Palliative care refers to medical interventions aimed at improving the comfort, quality of life, and dignified death of terminally ill people, which includes medical, emotional, and spiritual support for dying patients and their families [5]. This is done to relieve suffering, respect patient preferences, facilitate shared decision-making, provide information and support to families, and maintain dignity [6]. Although it is morally required to provide high-quality EOL care to dying patients, there are significant obstacles in bringing ICU culture and practices into compliance with palliative care principles [6]. Rather than gradually switching to comfort care sooner, aggressive and curative therapies are frequently prolonged until death is imminent [7]. This practice is mostly influenced by the availability of palliative resources, family dynamics, physician values, and prognosis uncertainty [8].

Nurses play a pivotal role in providing EOL care across settings from hospitals to home hospices. The continuous presence of nurses at patients’ bedsides enables the development of close relationships and places nurses in a central position to coordinate care, manage symptoms, provide psychosocial and emotional support, advocate for patients’ wishes, and guide family members through the dying process [9, 10]. Nurses are responsible for thorough symptom assessment and providing pharmacological and non-pharmacological interventions to maximize patient comfort as death nears. This can involve managing pain, dyspnoea, nausea, anxiety, delirium, and other distressing symptoms [11].

Healthcare professionals, including nurses working in ICU settings, have an ethical commitment to offer empathetic, patient-centred care to terminally ill patients and their families. However, multiple studies have highlighted difficulties and deficiencies in EOL care practices in the ICU setting globally and in Ghana specifically [12]. Common issues reported include inadequate integration of palliative care principles, lack of training and support for ICU providers in areas like communication and ethical decision-making, and persistent use of non-beneficial aggressive treatments instead of prioritizing comfort and quality of life as death nears [13, 14]. Bayuo and Baffour’s study in the ICU at Ghanaian tertiary healthcare facilities suggests that we equip care staff with general palliative care skills [15].

Practicing in an ethnically and culturally diverse society requires healthcare providers to understand, respect, and take into account the particular cultures from which their patients come [16]. A person’s cultural background profoundly shapes their experience of dying and death [17].

Importantly, there are limited studies that have focused on ICU nurses at Ho Teaching Hospital, a critical referral centre for the Volta and Oti regions. ICU nurses are uniquely positioned to understand the challenges and complexities of EOL care provision, given their frontline care responsibilities and close interactions with patients and families during this difficult period. However, there remains a dearth of knowledge regarding the experiences and perspectives of ICU nurses at Ho Teaching Hospital in Ghana, who regularly encounter patient deaths but may lack systemic support structures to enable the provision of optimal EOL care. Given the significance of this regional referral hospital, understanding ICU nurses’ specific needs and challenges is crucial to driving improvements in EOL care practices. This study aims to fill this gap by exploring ICU nurses’ experiences with EOL care at Ho Teaching Hospital. It will examine their emotional responses, challenges encountered, and recommendations for improving EOL care policies and practices within the Ghanaian ICU context.

Methods

Study design

This study employed an exploratory qualitative design using in-depth interviews. Exploratory qualitative research aims to explore perspectives and discover insights about a problem or phenomenon that is not well understood. This design enables a thorough, in-depth examination of nurses’ feelings, difficulties, and viewpoints, which is important considering the paucity of previous research on the subject in Ghana. This study was conducted in line with the consolidated criteria for reporting qualitative research (COREQ) checklist to ensure the quality of research [18].

Study population

A purposive sampling method was used to recruit participants who had the understanding of the research problem and the phenomenon of interest [19]. The participants comprised ICU nurses working at Ho Teaching Hospital who had direct experience providing EOL care to critically ill patients. Participants were recruited through the unit in charge to facilitate access to eligible nurses based on predefined inclusion criteria. To be included, participants were to be registered nurses currently practicing in the ICU setting with a minimum of 12 months of experience caring for patients. The sample size was determined based on data saturation, which was assessed through an iterative data collection process. Data saturation is reached when there is enough information to replicate the study, and the ability to obtain additional new information has been attained [20]. The study recruited a total of 20 nurses to reach saturation.

Data collection

Data collection involved conducting in-depth, semi-structured interviews with participants, allowing for detailed personal perspectives and experiences to be captured [21–23]. Interviews for this study were scheduled with participants’ agreement if they satisfied the inclusion criteria. The idea behind choosing the interview setting was to allow the interviewees to share their stories. An interview guide was developed based on key topics from the literature review, focusing on nurses’ experiences providing EOL care in the ICU, communication dynamics, perceived challenges, support sources, and suggestions for improvement. The guide evolved during data collection to address emerging topics. The interviews were conducted in English, the official language in Ghana. Each interview lasted between 30 and 45 min. A research assistant, who had no prior interaction with the participants, promptly transcribed the audio-recorded interviews. The research assistant was employed to ensure neutrality in transcription, minimizing researcher bias and enhancing data credibility. His lack of prior interaction with participants reduced the risk of selective interpretation, ensuring accuracy and reliability in the study’s findings.

Data analysis

Thematic analysis was employed to identify and analyse themes within the qualitative interview data through an inductive approach, following the six phases outlined by Maguire and Delahunt [24]. This method involved identifying patterns in the meaning of the data through repeated reading of transcripts. Initial codes were generated to capture key features, from which potential themes reflecting research aims were developed. Themes were refined by comparing them against coded extracts and the full dataset, with clear definitions and names created for each. The analysis culminated in a scholarly report connecting findings to research aims and literature. NVivo qualitative data analysis software facilitated organization, coding, and theme development [25].

Rigour

Rigorous qualitative research design, essential for trustworthiness, involves strategies like purposive sampling, iterative analysis, reflexivity, audit trails, peer debriefing, and data saturation [26]. These enhance credibility, dependability, confirmability, and transferability of findings [27]. Credibility was ensured through member checking, triangulation, and prolonged engagement [28]. Dependability was strengthened by audit trails and triangulation, while confirmability was enhanced by reflexivity and peer debriefing [29]. To ensure reflexivity, the researchers practiced continuous self-reflection throughout the study process, recording their assumptions, viewpoints, and any biases in reflexive notebooks. Team meetings were held regularly to critically investigate how researchers’ backgrounds, roles, and relationships with participants can affect data gathering and interpretation. This reflective method reduced prejudice and supported the openness and honesty of the analytical process. Transferability was supported by providing detailed data descriptions, context, and assumptions [16].

Ethical consideration

The study ensured adherence to ethical principles, including privacy, confidentiality, safety, respect for participants, beneficence, and non-maleficence. Written informed consent to participate was obtained from all of the participants in the study. Interviews were conducted at convenient times and places to maintain privacy. Confidentiality was guaranteed, and participants could withdraw without consequences. The University of Health and Allied Sciences Research Ethics Committee provided clearance for the study. The study followed the principles and guidelines of the Declaration of Helsinki. Clinical trial number: not applicable.

Findings

Socio-demographic profile of the participants

Out of the 20 participants involved in the study, the majority, eleven (55%), were males. Regarding age, the youngest and oldest participants were twenty-five (25) and thirty-seven (37), respectively. Most nurses, thirteen (13), identified as senior staff nurses. With work experience, the lowest work experience was two (2) years, and the most experienced participant had fifteen (16) years of work experience. Their demographic data are represented in Table 1.

Table 1.

Socio-demographic characteristics of study participants

Variable	Categories	Number
Age
	20–30	11
	31–40	9
Sex
	Female	9
	Male	11
Job title
	Staff nurse	5
	Senior staff nurse	13
	Nursing officer	1
	Principal nursing officer	1
Years of experience
	1–5	6
	6–10	3
	11–15	10
	16–20	1

Source: Field Data, 2024

Organization of emerged themes and sub-themes

Table 2 presents a summary of themes and sub-themes that emerged from the data collected. In all, three (3) thematic themes and their corresponding sub-themes emerged from the interviews conducted after the data analysis.

Table 2.

Presentation of emerged themes and Sub-Themes of study

THEMES	SUB-THEMES
Emotional Burden	1. Sorrowful sentiments 2. Emotional Attachment and Connection
Challenges Encountered when Providing End of Life Care	1. Limited Human and Material Resources. 2. Cultural and Familial Challenges in Providing ICU Care. 3. The Impact of Spiritual Beliefs and Practices on ICU Care.
Improving End-of-Life Care in the ICU.	1. Upgrading Equipment and Resources in the Unit. 2. Training of ICU Nurses’ in Critical and Mental Health. 3. Improved communication. 4. Increasing Staffing. 5. Motivation

Theme one: Emotional burden of end of life care

This theme discusses what the nurses have experienced while working in the ICU. Two sub-themes, including negative emotional feelings nurses go through, nurses becoming more connected with patients, patient’s outcomes on nurses’ experiences, guilt feeling when the outcome is negative, empathizing with patients’ suffering, and acceptance of outcome due to limitations give a comprehensive description of the experiences of the participants.

Sub-theme one: sorrowful sentiments

Here, the participants expressed experiencing a range of unpleasant emotions when providing EOL care, including depression, torment, stress, anxiety, fear, frustration, and a sense of failure. The emotional challenges stemmed from witnessing patients suffering and dying, feelings of helplessness in being unable to cure patients, and the difficulties in accepting that care is focused solely on EOL management. Nurses found the experience emotionally demanding and depressing. Several participants highlighted the negative emotional burden, as evident in these quotes:

Experiences are always bad when you see someone die. At times, you think you can help the patient recover, but you don’t really have control over the person’s life. You can just help the person by hoping that he or she will recover… (P7)

You think you can help the patient recover, but you don’t really have control over somebody’s life. You can just help the person, hoping that the person will recover. So, the experiences are always bad when you see somebody die. (P1)

As a human being, nurses will feel very bad, knowing these patients will die, but if the things are not there for you to take care of the patient, the patient finally passes on, we(nurses) feel like doing something; we (nurses) feel like there is something we need to do but we are not able to do and that resulted in patients’ death. (P12)

…we feel that it’s a failure on our side because seeing a patient dying, our main motive is to get the patient well to go home to their family. However, seeing a patient dying in our hands psychologically gives us a mindset of failure and frustration. (P20)

Sub-theme two: Emotional attachment and connection

Some nurses discussed how they formed strong ties with dying patients, which made the experience more emotionally involving. Nurses demonstrated empathy towards the suffering experienced by dying patients and their families. As they feel it could also happen to them. Participants stated:

It is such an emotional state, especially when you become so attached to this client and their relatives, day in and day out, as nurses provide care. Some nurses, patients, and relatives eventually become so close that nurses feel the physical, psychological, and emotional pain the patients go through. (P11)

Knowing that the patient is just dying, and you cannot at that moment do anything, it’s not a pleasant experience at all. Staying by their side until the very end involves a lot of emotions, I would say. (P5)

…we cry on duty because of the bond we’ve created with them throughout our stay with these patients.. (P8)

Theme two: Difficulties ICU nurses encounter when providing End-of-Life care

This theme captures the challenges the nurses encounter in providing care. The sub-themes further expand on some of these key challenges.

Sub-theme one: Limited human and material resources

Several nurses cited lack of essential equipment, supplies, and medications (emergency drugs, faulty equipment, lack of vital sign monitors, oxygen supplies) as major obstacles in delivering quality EOL care in the ICU. The limited availability of resources severely hampered their ability to provide adequate care. Notwithstanding, understaffing was also another major issue affecting the delivery of quality EOL care. Some participants narrated:

Sometimes you need a specific drug, but you may not get it. Emergency drugs, like adrenaline, ethylpneum, amiodarone and the rest sometimes get out of stock which really affects the care rendered. (P1)

We face a lot of challenges with equipment like flow meters, and oxygen, sometimes oxygen is not available, and other times thermometers are not working. These may look minor, but they affect the quality of work we give. (P12)

…most of the time, the number of nurses is inadequate. So, sometimes we are understaffed when it comes to work like this. we need to be adequate; something what three nurses are supposed to do, one person will be doing it, and in that case, you see that this ends up affecting the quality of work. When the nurses are exhausted, it is the quality of care that will be affected. (P16)

Sub-theme two: Cultural and familial challenges in providing ICU care

Majority of the nurses highlighted difficulties arising from lack of cooperation and unrealistic expectations from patients’ families that conflicted with medical care. Families’ refusal to accept prognoses, demands for certain treatments against medical advice, and lack of financial resources posed significant challenges. Communication challenges in conveying prognoses to families and managing their emotional responses added further difficulties. These nurses stated:

…one of the challenges I will talk about is the refusal of treatment. As I spoke about earlier, a patient who refuses blood transfusion is a challenge to the nurses and doctors at large, as patients and relatives believe blood transfusing is evil… (P6)

…mostly the challenges are from the relatives, since they know the patient is about to die, the prognosis is very bad and the patient will pass on soon, they are not cooperative as they do not want to waste resources (P7)

There are some families who will even start preparing for burials, while the patient has not died. In such instances, they will no longer cooperate with treatment because they believe whatever they do won’t bring the relative back but will be a waste of resources. (P8)

Sub-theme three: The impact of spiritual beliefs and practices on ICU care delivery

The findings here show that families bring traditional herbs, concoctions, and objects like ropes, talismans, and toys to the hospital and secretly give them to patients or place them under pillows or beds; they perform rituals; they invite spiritual leaders to pray for patients against the medical team’s advice and some families take patients away from the hospital against medical advice to pursue traditional or spiritual healing methods. Given this, some stated:

In this vicinity, where we find ourselves, a lot of people believe in spirituality. … and then they sometimes hide some objects behind the beds of our clients, sometimes even in their pillows. There are lots of ropes and other images and objects that have been kept there. sometimes even during their feeding and then serving of medication. They use (drink or apply on the skin) concoctions, and even though we are vigilant in rendering care, they try to act smart and use them because they believe the month or the number of days the patient has stayed in the facility should not be so. Relatives sometimes bring in those spiritual objects and believes these objects will fasten healing, and then it rather implicates things for us. (P2)

At times there are instances where the patient is critically ill, relatives try to outsmart nurses to bring in smaller gods to be with the patient. Sometimes they invite their pastors or spiritualists as well, even at odd times when they are not supposed to. (P14)

…at times when changing bed linings, you realize there are some herbs or wooden toys under the pillow. Sometimes they tie some things around their hand, like talismans while others tie various colours of cloth, I don’t know whether it is a stone they tie it on their hand. Some powders were also seen on patients’ foreheads. (P15)

At times, while you (nurses) are giving the orthodox medicine; they (relatives) are giving the herbal preparations. At times, you (nurses) will be caring for the patient, and then you (nurse) realize that it’s reached a point where the patient is recovering, then they (relatives/patient) will bring a letter stating that they (relatives/patient) want to be discharged against medical advice thinking that the disease is caused by someone or a spirit. (P9)

There were instances where families, and religious beliefs like not accepting blood transfusions (Jehovah’s Witnesses), conflicted with medical treatment. A participant stated:

One that keeps ringing in my ears is the Jehovah’s Witness patient that I cared for. So, we need to transfuse blood. Her HB was low, but due to their belief that they don’t transfuse blood, we tried to convince but it took about two days before the family agreed that we should transfuse in the night so that people would not see. But after the transfusion, the patient survived for only a week and died. (P1)

Theme three: Improving end-of-life care in the ICU

Sub-theme one: Upgrading equipment and resources in the unit

Participants mentioned the need for up-to-date, well-functioning equipment like ventilators, cardiac monitors, suctioning machines, flow meters for oxygen therapy, availability of emergency medications, wound dressing supplies, etc. Improve infrastructure like power backup, CCTV monitoring, and providing proper beds and mattresses for patient comfort. participants narrated:

Ventilators must be up-to-date, not old function donated kind of ventilators. Our cardiac monitors must be up-to-date. When the expiring dates reach for the machines, they must be removed and replaced. So that always we(nurses)will have the hope that oh, this machine will give me accurate information. (P1)

Okay, some of the things that need to be improved upon will be security. The security of the wards should be improved, if there are some CCTV cameras available for us to have persistent monitoring on the clients, it will go a long way toward saving our patients. (P2)

At times, you need a flow meter and It’s not adequate, at times they are fault hence the right amount that the patient is supposed to get, the patient isn’t getting it. We need suctioning machines at times the machines are there but are faulty. We use ventilators, pulse oximeters, monitors, and a whole lot more. We need a lot to give our best care to the patient. (P9)

We need better and adjustable beds with good mattresses, and any equipment that will make the client comfortable, that is, nursing the client to a peaceful death. we need such equipment in our facilities to help improve our health care delivery. (P11)

Sub-theme two: Training of ICU nurses in critical and mental health

Providing specialized, continuing training for ICU nurses in EOL care competencies, assessing and supporting the psychological and mental health needs of ICU staff periodically, and training of nurses on the proper use of ICU equipment were the improvements highlighted.

some participants expressed similar ideas in the following quotes.

Training of our staffs also needs to be improved, as this will help us be up to date with the current procedures and management of our patients. (P3)

Improving upon specialized training of nurses and doctors in competencies needed in the area of end-of-life care can also go a long way to help us. (P4)

Another thing that I want to talk about is that we nurses working in the ICU should be assessed periodically for our psychological health status, and if the need be, health assistance will be received to help us psychologically, as some of us may be facing some challenges at home and the workplace. (P18)

Education is key; hence the nurses have to be taught how to use the machines available as nurses’ work is not only treating and feeding the patient. We nurses need to be taught how to use the machines and the various meanings of the indicators as some of the machines indicate what a sound means or what the color of the machine indicates, this can help nurses to quickly inform the doctor or intervene before a doctor arrives. (P8)

Sub-theme three: Improved communication

Participants emphasized on the hospital’s need to improve communication between staff and patients or families, use of effective communication tools, respect cultural beliefs while providing standard care.

The way we (nurses) communicate with the client’s relatives is an important key in the care we (nurses) render. Inasmuch as some of them believe in spiritual stuff, they have decided to bring their wards to the hospital for us to render care. Talking to patients and relatives rudely will not make them help us in rendering care. Also, we need to respect their (patients’ and relatives) beliefs and let them (patients and relatives) know our side of the care as well and then cooperate with them, because if we always neglect their beliefs, trying to force them to believe in ours just to render the best care to our clients, there won’t be 100% care for them. So, we have to communicate well, respect, and be nice to them. Let them understand the care through effective communication for proper comprehension and cooperation. (P2)

And secondly, the way of communication is not just a matter of informing patients, rather communications with patient and relatives should be put in cases like how communication tools such as ISBA and COO are used. (P20)

Sub-theme four: Increasing staffing

Findings reveal that there should be an adequate number of staff, especially nurses, to improve patient-nurse ratio and ensure adequate staff strength is available at all times.

One participant explained:

Staff strength is relevant in rendering nursing care in the ICU. Yes, if there are three beds in the ICU, at least three staff must be on duty, not having maybe five beds, then two staff, or six beds to two staff who will be trying to manage these clients. While it’s human life that we are caring for, we don’t have to manage, and this needs to be improved. (P1)

When the unit don’t have the staff strength at a particular point in time, then you (nurse) have to leave it until someone comes in to help, which is bad. And we know attending to patients like this is supposed to be done very early. (P7)

. In the ICU too, we need more staff so that there will not be pressure on the staff on duty so that the best care can be given. At times, the patient-to-nurse ratio is so bad that you can’t give the best care to the patient at a given time. (P9)

Sub-theme five: Motivation

While passion was clearly a key motivator, some nurses did point to limited external factors that helped motivate and support them. Positive reinforcement, recognition from superiors, and professional development opportunities were some of the motivations that were mentioned.

I can say the support we get from our superior, the one in charge, is that you are doing a good job. Keep it up. Once in a while, you get some sachets of cowbell coffee as your night package and then some biscuits, which I think is inadequate. (P11)

Every month the authorities organize a workshop or in-service training for some of us and then some hands-on practical for us to have that experience, also there is unity and teamwork among the staff here, the in-charge of the unit is understanding and lively to work with and that alone make nurses want to put in their best to care for the patient. (P13)

Discussion

This study aims to explore the experiences of nurses providing EOL care in the intensive care unit at Ho Teaching Hospital in Ghana. The findings of this study revealed that most of the nurses experienced diverse emotional impacts of EOL care in the ICU. Negative emotions, such as depression, stress, anxiety, fear, and feelings of failure and frustration, were prevalent among nurses providing EOL care, echoing existing literature on the emotional toll and burnout associated with such care in ICU settings [30, 31]. The researchers noted that nurses often experience guilt when patients do not recover despite their efforts, highlighting the need for emotional support and coping strategies in high-stress environments like the ICU, consistent with previous research by Kharatzadeh et al. [32]. Moreover, nurses reported becoming more connected with patients, forming close bonds that lead to heightened emotional involvement, as documented in a prior study [33]. While this connection may provide personal fulfillment, it can also contribute to emotional distress when patients do not recover, underscoring nurses’ ability to empathize with patient suffering and aligning with the nursing profession’s core values of compassion and caring [17].

Nurses also expressed acceptance of outcomes due to limitations, acknowledging their inability to control life and death and accepting their role in providing comfort and a peaceful death when curative measures are no longer possible. This finding aligns with previous research emphasizing the importance of palliative care principles and recognizing the inevitability of death despite healthcare professionals’ best efforts [34].

The study revealed significant challenges related to limited human and material resources, including shortages of essential equipment, supplies, medications, and inadequate staffing, affecting the quality of EOL care delivered by nurses. These findings align with previous research [35], documenting the adverse effects of resource constraints on palliative and EOL care provision, particularly in resource-constrained environments. For instance, a previous study [35] highlighted the barrier posed by inadequate access to essential medications, while others emphasized the impact of insufficient staffing and material resources on EOL care quality in intensive care units. The systemic barriers observed in this study are linked to limited Opportunity in the COM-B framework. Lack of staff, lack of essential supplies, and inadequate institutional support impede nurses’ opportunities to deliver quality EOL care. This reflects the Structural Component of Palliative Care Models, which calls for system-level support (resources, training, and policy) to enable effective care delivery.

Additionally, challenges arose from family members’ non-compliance with care, stemming from unrealistic expectations, cultural beliefs, and financial constraints. These findings are consistent with previous studies [36, 37], which highlighted the complexities in healthcare professionals’ interactions with patients’ families during EOL care. The study emphasizes the need for culturally sensitive communication and care approaches to address these challenges.

Also, the study identified challenges posed by families’ use of traditional medicine and ritual practices, which often conflicted with standard medical care. These factors intersect with the social opportunity dimension in the COM-B model and highlight the necessity for culturally competent care strategies, a tenet al.so central to palliative care frameworks. These findings align with prior research by [38], documenting the persistent use of traditional and complementary medicine practices, particularly during critical illness and EOL care. The study underscores the importance of integrating traditional healing practices with conventional medical care in a culturally sensitive manner.

Furthermore, the influence of religious and spiritual beliefs on EOL decision-making and care was noted, as documented by [39, 40]. These studies found that religious beliefs, such as the refusal of blood transfusions by a religious group, significantly impact medical treatment and patient outcomes, highlighting the need for healthcare professionals to navigate these beliefs respectfully and effectively.

The study findings on the importance of upgrading equipment and resources (essential medications, adjustable beds, and monitoring systems) in the ICU resonate with prior research by [41, 42], emphasizing the necessity of up-to-date equipment, availability of essential medications, and improved infrastructure for delivering high-quality EOL care. The researchers stress the critical role of adequate resources and infrastructure in ensuring quality care during end-of-life situations.

Moreover, the findings highlight the importance of training ICU nurses in critical and mental health, aligning with previous studies [31, 32, 43]. Specialized training in EOL care competencies is found to improve healthcare professionals’ knowledge, attitudes, and confidence in providing care, emphasizing the need for ongoing professional development to support ICU staff in high-stress environments.

Additionally, the study emphasizes the importance of improved communication, which is consistent with findings from previous studies [44–47]. Effective communication, cultural sensitivity, and logistical support are vital for healthcare professionals involved in EOL care, promoting patient-centered care delivery.

Lastly, the findings emphasize the importance of adequate staffing levels, motivation, and support for ICU staff, in line with prior research [31, 32, 46]. Limited external factors, such as positive reinforcement, professional development opportunities, and psychological support, play crucial roles in promoting job satisfaction and well-being among healthcare professionals involved in EOL care.

Limitations of the study

Although this study offers insightful analysis of the experiences of nurses delivering EOL care in the ICU at Ho Teaching Hospital, many limitations should be noted and, therefore, acknowledged. First, as this was a qualitative study involving interviews, there is potential for social desirability bias. Second, the study was conducted at a single tertiary hospital in Ghana, which may limit the generalisability of the findings to other settings. Finally, while efforts were made to ensure rigor through strategies such as member checking, audit trails, and reflexivity, researcher bias in data interpretation remains a potential limitation.

Conclusion

This study highlights the emotional burden nurses face, including feelings of depression, stress, anxiety, and failure, alongside their resilience, empathy, and ability to form meaningful connections with patients. Significant obstacles to quality care are identified, such as resource shortages, non-adherence to treatment, and cultural and religious barriers. The study proposes that the hospital could establish a structured EOL care training program, integrating it into ICU nurses’ continuing education. Mandatory counselling sessions should be implemented under the supervision of the hospital’s wellness committee to ensure the well-being of staff. There should also be an improvement in resources and enhanced institutional support systems, including better remuneration and professional development opportunities. It concludes by emphasizing the need for a comprehensive approach to improve EOL care in resource-limited settings, enhancing both patient and nurse experiences and promoting a supportive environment for high-quality, compassionate EOL care.

Future research should focus on intervention-based studies to assess the effectiveness of proposed support systems, training programs, and counselling services in meeting the emotional and practical needs of ICU nurses.

Author contributions

A.F.D. conceived the study and analyzed and wrote the manuscript. B.B.J., E.K., J.Z., B.O., R.A., J.A.A., B.E., and A.A., conducted the literature search and wrote the Manuscript. All the authors reviewed and provided intellectual content and modifications and approved the final draft of the manuscript.

Funding

The study was self-funded by the researchers.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethical approval

The researchers sought ethical review and clearance from the Research Ethics Committee of the University of Health and Allied Sciences before commencing data collection. Written informed consent to participate was obtained from all of the participants in the study. The study followed the principles and guidelines of the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.