“Caring in a liminal space”: a constructivist grounded theory study examining nurses’ approach to end-of-life care provision in acute care settings

Emergency Departments (EDs) and Burn Intensive Care Units (BICUs) frequently care for critically ill patients who may require comfort-focused, end-of-life support. Yet palliative care integration in these traditionally non-palliative environments remains limited. This gap raises important questions about how nurses navigate and deliver end-of-life care in acute settings. This study explored the processes underpinning nurses’ provision of end-of-life care in the ED and BICU. A constructivist grounded theory approach, informed by Charmaz, guided the study. Initial purposive sampling followed by theoretical sampling was used to recruit nurses with at least six months of experience in either unit. Data were collected through semi-structured interviews, participant observation, and document review. Analysis followed the constant comparative method. Twenty-seven nurses participated. The core category, “ caring in a liminal space ,” captured nurses’ experiences of navigating an uncertain and often disorienting care environment in which they felt insufficiently prepared to provide end-of-life care. Three interrelated categories explained this core process- (1) journeying through an undesired, fractured space, (2) engaging in active-passive care processes, and (3) carrying concealed professional grief. Across both settings, nurses tended to adopt a vicarious, survival-oriented approach to care, prioritizing life-sustaining interventions even when comfort care was more appropriate. The end-of-life space was described as emotionally and professionally uncomfortable, contributing to a reliance on active clinical tasks rather than comfort-focused care. These findings demonstrate that nurses’ end-of-life practices in acute care are shaped less by individual deficits and more by the structural liminality inherent in ED and BICU environments. Strengthening palliative care integration therefore requires system-level reforms such as embedded palliative care teams, supportive organisational cultures, and clearer care pathways alongside targeted education and interdisciplinary collaboration. Such changes are essential to improve the quality of end-of-life care for patients and families and to better support nurses as they navigate the persistent tensions of this liminal space.