A total of 33 nurses aged between 29 and 51 years participated. The majority of participants were cisgender women (n = 20). Most had a bachelor’s degree (n = 24), whereas all others had a master’s degree. Participants had a work experience of between 7 and 18 years. Their history of caring for end-of-life those with heart failure varied from 6 months to 11 years.

Overall, the challenges to nurses providing end-of-life care to those with heart failure were determined and classified in two main categories (1) adverse consequences of end-of-life care and (2) lack of palliative care services. Subcategories relating to adverse consequences of end-of-life care included (1) dealing with compassion fatigue and (2) continued futility in care. Subcategories relating to lack of palliative care services included (1) lack of specialists, (2) lack of support from health systems, and (3) poor teamwork. These main categories and subcategories are described below, with salient quotes used to highlight some of the particular meanings identified.

Adverse consequences of end-of-life care

According to nurses, there is a diversity in adverse consequences when providing end-of-life care to those with heart failure. On the one hand there is nurses dealing with compassion fatigue. On the other hand, there is seemingly a continued futility in providing care. This dichotomy seemingly ignited emotional conflict and a degree of distress among participants, whose professional identity grounded them toward a desire to do the best for their patients, despite the adverse consequences.

Dealing with compassion fatigue

Providing end-of-life care to those with heart failure was perceived to affect the mental wellbeing of nurses. Indeed, the narratives of nurses indicated that they had been experiencing compassion fatigue due to prolonged immersion in the grief and suffering of those affected by heart failure. Beyond compassion fatigue, participants describe nightmares, associated physical symptoms and reference feelings of anxiety and worthlessness. This is concerning as the poorer physical, emotional, social and spiritual health of healthcare providers associated with compassion fatigue can impact the delivery of services [15].

“Keep taking care of end-of-life heart failure patients has made me nervous. I am constantly anxious. I feel very tired and have headaches and dizziness, and these are really painful because I think I am drowning in the suffering of these patients. I must say that under these challenging conditions, the quality of care for those patients who really have nothing left at the end of their lives is greatly reduced.“ (Participant (P) 5).

“Seeing the death of heart failure patients affects me emotionally and makes me feel worthless. I think so much about the patients who are on the verge of death and then die. It even affects my relationships with others so that I distance myself from friends, acquaintances, and relatives… You may not believe it, but I see nightmares of the dead patients at night because dead patients come to my sleep.“ (P11).

Continued futility in care

When there is no opportunity to prolong the life of patients with heart failure, from the perspective of nurses, there is seemingly little point in continuing to provide care for them. In this sense there was seemingly lower job satisfaction where nurses were no longer able to preserve life, particularly where there was little instruction as to what to do in such scenarios. This perceived futility may be indicative of the role of the nurse being in conflict with the demands of the service in this context. For example, the following participant describes the prolonging of life being futile where death is inevitable. Such reflections may suggest that end-of-life care is not designed for dignity in this context, which professionally conflicts with the role of the nurse.

“We don’t have a single instruction in the country that allows us to take care of a heart failure patient at the end- of- life in such a way that futile care is not repeated for the dying patient! For example, why should care be continued for patients who have an ejection fraction of less than 10% for a long time and there is no hope for their progress?” (P24).

Indeed, as the following participant describes, it is law which promotes the prolonging of life in favor of dignity in dying. Such conflicts with the professional role of the nurse may cause further emotional harm for nursing professionals.

“When a patient becomes dependent on dopamine, if dopamine is cut off, he will surely die. Such patients have no resuscitation order and caring for them is practically a futile task… However, the same patient should be treated and receive CPR, if necessary, because in our country, no resuscitation law has not yet been approved by the Ministry of Health!“ (P8).

Lack of palliative care services

Nurses’ narratives indicated that service-related factors such as a severe shortage of specialists, a lack of support from health systems, and poor teamwork led to challenges in providing adequate palliative care. In this context, palliative care is used to describe a broad concept inclusive of end-of-life care.

Severe shortage of specialists

The lack of specialist medical professionals in the field of palliative care is challenging when providing end-of-life care for those with heart failure. With such a lack of services, some illnesses and geographical areas were perceived to be prioritised for end-of-life care above others. This was frustrating to participants, who equated this to being notably underserved and under recognised in their area of work.

“While palliative care can improve the quality of life of heart failure patients, in our country it is practically ignored for heart failure patients because we do not have palliative care specialists. In Iran, palliative care is only for cancer patients, and even it does not exist for everyone or all parts of the country. Now, although we are in the capital, we don’t even have a doctor specializing in palliative care for heart failure patients”. (P19)

Nurses reported that in particular, the lack of a master’s degree program in palliative care in our universities leads to a lack of palliative care nursing specialists to provide end-of-life care for these patients. This, partnered with a lack of priority setting in this area was perceived to be a key barrier in providing high-quality end-of-life care. Such findings indicate a need for enhanced education, and recognition of the need for specialized palliative care nurses in this speciality.

“In Iran, there is no master’s degree in palliative care at universities, as a result, specialist nurses are not trained in this regard. Consequently, the lack of palliative care specialists does not allow palliative care at the end-of-life to be implemented for patients in general and for heart failure patients in particular.“ (P30).

Lack of support from health system

One of the challenges of end-of life -care perceived by nurses was the lack of support from health system to provide palliative care services for those with heart failure patients at the end- of their life. This, partnered with a lack of specialists in the field, led to further sentiments conveying a lack of respect and value placed upon high quality end-of-life care in this context. One suggestion for this was driven by perceived financial incentives.

“The main problem is that palliative care for heart failure patients has no place in Iran… Palliative care services do not generate income for the government, so it is not worth it for the government to set up palliative care centers for patients. In fact, the health system does not provide any support in this regard. This causes us to face a severe lack of palliative care services for people with heart failure, especially at the end-of-life phase.“ (P15).

Nurses understood the value they could potentially bring to those with heart failure in need of high-quality end-of-life care. Despite this, they remained frustrated that the benefits they could bring had not been considered or prioritised, as the following quote demonstrates;

“Palliative care can meet the physical, spiritual and psychological needs of heart failure patients at the end- of- life, but the problem is that centers for this type of care have not been considered by the health system, and I must say that health system has no support approach in this context.“ (P21).

Poor teamwork

High quality teamwork was perceived to be important in the provision of high-quality end- of- life care. However, teamwork was perceived to be poor and fragmented, leading to an absence of palliative care services when required. Communication, a key competence of nursing professionals, was considered to be key in this, particularly with regard to interprofessional working. Yet seemingly no training or processes were in place to facilitate this. Evidently, distinct “attention should be paid to the communication between people from different professions in the form of a palliative care team” (P27).

“In my opinion, teams that provide palliative care to heart failure patients are weak and fragmented in terms of communication. In order to provide palliative care to these patients, communication between different specialists in interdisciplinary teams must be coherent and coordinated and effective interactions should exist… For example, for spiritual counseling, the relevant specialist should cooperate with the cardiologist. Also, the psychologist and nurse should cooperate with the rest of treatment team, but the fact is that the team communication is very weak, and this causes a big challenge for palliative care.“ (P1).

Moreover, nurses described professional conflict with regards to medical and nursing staff as being something which would further hinder progress, even if effective services were to be established. Such professional conflicts may result from gender related oppression with regards to these professions and potential hierarchy in teams. Distinct programs of work to address these conflicts will be key to unlocking the potential of high-quality end-of-life care delivered in this context.

“I think that even if palliative care was established in our country like the developed countries, the provision of palliative care for heart failure patients at the end-of-life phase still fails, because the medical and nursing staff do not have the team spirit for effective teamwork.“ (P33).