Existential encounters: nurses' descriptions of critical incidents in end-of-life cancer care

Nurses' models of spiritual care: A cross-sectional survey of American nurses

OBJECTIVES

Despite there being many models for how spiritual care should be provided, the way nurses actually provide spiritual care often differs from these models. Based on the premise that the way a person enacts their work role is related to how they understand that role, this study aims to describe the qualitatively different ways that nurses understand their spiritual care role.

METHODS

A convenience sample of 66 American nurses completed an anonymous, online questionnaire about what spiritual care means for them and what they generally do to provide spiritual care. Their responses were analyzed phenomenographically.

RESULTS

Four qualitatively different ways of understanding emerged: active management of the patient's experience, responsive facilitation of patient's wishes, accompaniment on the patient's dying journey, and empowering co-action with the patient. Each understanding was found to demonstrate a specific combination of 5 attributes that described the spiritual care role: nurse directivity, the cues used for spiritual assessment, and the nurse's perception of intimacy, the patient, and the task.

SIGNIFICANCE OF RESULTS

The findings of this study may explain why nurses vary in their spiritual care role and can be used to assess and develop competence in spiritual care.

Moral Challenges of Nurses and Volunteers in Dutch Palliative Care. A Qualitative Study

Objective: To identify moral challenges experienced by nurses and volunteers in palliative care. Methods: A qualitative hermeneutic research design was used. Interviews with nurses (N = 10) and volunteers (N = 4) working in palliative care, in-home care, and hospice setting. Participants were recruited through maximum variation, a purposive sampling technique. Transcriptions were analyzed using qualitative thematic content analysis and open coding. Results: Two themes were identified, each with three subthemes: theme (A) Moral challenges regarding organizational and professional aspects contained the subthemes (1) dealing with protocols and regulations, (2) different professional perspectives on good care, and (3) limits of professionalism. Theme (B) Moral challenges regarding the patient and their family members contained the subthemes (1) dealing with the patient's wishes, (2) the patient's wish to die, and (3) dealing with family members. Conclusion: Nurses and volunteers working in palliative care are confronted with a wide range of moral challenges. Insight into 'real-world ethical challenges' of healthcare providers is important to provide adequate support to nurses and volunteers working in palliative care.

Factors influencing nurse spiritual care practices at the end of life: A systematic review

OBJECTIVES

The aim was to identify determinants of nurse spiritual/existential care practices toward end-of-life patients. Nurses can play a significant role in providing spiritual/existential care, but they actually provide this care less frequently than desired by patients.

METHODS

A systematic search was performed for peer-reviewed articles that reported factors that influenced nurses' spiritual/existential care practices toward adult end-of-life patients.

RESULTS

The review identified 42 studies and included the views of 4,712 nurses across a range of hospital and community settings. The most frequently reported factors/domains that influenced nurse practice were patient-related social influence, skills, social/professional role and identity, intentions and goals, and environmental context and resources.

SIGNIFICANCE OF RESULTS

A range of personal, organizational, and patient-related factors influence nurse provision of spiritual/existential care to end-of-life patients. This complete list of factors can be used to gauge a unit's conduciveness to nurse provision of spiritual/existential care and can be used as inputs to nurse competency frameworks.

Existential aspects documented in older people’s patient records in the context of specialized palliative care: a retrospective review

Background

Documentation of older people’s end-of-life care should cover the care given and provide an overview of their entire situation. Older people approaching the end of life often have complex symptoms, live with bodily losses, and face an unknown future in which existential aspects come to the forefront. Knowledge of the existential aspects recorded in palliative care documentation is sparse and merits improvement. This knowledge is relevant to the development of more holistic documentation and is necessary in order to promote reflection on and discussion of documentation of the sensitive existential considerations arising in palliative care. The aim of this study was to describe the documentation of existential aspects in the patient records of older people receiving specialized palliative care.

Methods

Data were obtained from a retrospective review of the free-text notes in 84 records of randomly selected patients aged ≥75 years enrolled in specialized palliative care units who died in 2017. The notes were analysed using an inductive qualitative content analysis.

Results

The notes documented existential aspects in terms of connotations of well-being and ill-being. Documented existential aspects were related to the patients’ autonomy concerning loss of freedom and self-determination, social connectedness concerning loneliness and communion, emotional state concerning anxiety and inner peace, and state of being concerning despair and hope. The notes on existential aspects were, however, not recorded in a structured way and no care plans related to existential aspects were found.

Conclusions

Existential aspects concerning both ill-being and well-being were sparsely and unsystematically documented in older people’s patient records, but when notes were extracted from these records and analysed, patterns became evident. Existential aspects form an important basis for delivering person-centred palliative care. There is a need to develop structured documentation concerning existential aspects; otherwise, patients’ thoughts and concerns may remain unknown to healthcare professionals.

Nurses' experiences of supporting patients requesting voluntary assisted dying: A qualitative meta-synthesis

AIM

Describe the reported lived experiences of nurses who have participated at any stage of voluntary assisted dying (VAD), from the initial request to the end of life.

DESIGN

A qualitative meta-synthesis.

DATA SOURCES

Databases searched were CINAHL, MEDLINE, Emcare, Scopus and PsycInfo. The search was undertaken in September 2021 with no date limitations. Qualitative studies were considered if published in English, reported primary data analysis of nurses' experiences who had been involved in VAD and reported direct quotes from nurses.

REVIEW METHODS

Qualitative studies meeting the selection criteria were critically appraised, then an open card-sort method was applied. Quotes from nurses were organized to group similar experiences, constructing themes and metaphors across studies as a new understanding of nurses' experiences of VAD.

RESULTS

Eight studies were included. Three major themes were constructed: An orderly procedure, reflecting the need for structure to feel adequately prepared; A beautiful death, reflecting the autonomy the patient exercised when choosing VAD facilitated an exceptionally positive death; and Psychological and emotional impact, where nurses recognized the emotional and ethical weight that they carried for themselves and the team when undertaking VAD.

CONCLUSION

Nurses may benefit from clear policy, supervision and communication training to support them as countries transition to providing VAD services. Policy provides nurses with confidence that they are undertaking the steps of VAD correctly and provides a layer of emotional protection. Communication training specific to VAD is necessary to prepare nurses to recognize their own emotional experiences when responding to the needs of the patient and their family.

IMPACT

VAD is increasingly becoming a legal option that nurses are encountering in their professional practice. Understanding nurses' experiences of being involved in VAD is required to support nurses in countries where VAD is becoming available to prepare professionally and psychologically.

Impact of an education program to facilitate nurses' discussions of existential issues in neurological care

OBJECTIVES

Discussing existential issues is integral to caring for people with acute, progressive, or life-limiting neurological illness, but there is a lack of research examining how nurses approach existential issues with this patient group and their family members. The purpose was to examine the experiential impact of an educational program for nurses designed to facilitate discussions of existential issues with patients and family members in neurological wards.

METHOD

Nurses in inpatient and outpatient care at a neurological clinic in Sweden were invited to participate in an education program about discussing existential issues with patients and their family members as related to neurological conditions. The evaluation of the program and of the nurses' view of discussing existential issues was conducted through focus groups before and after participation. The data were analyzed by qualitative content analysis.

RESULTS

The program gave nurses a deeper understanding of existential issues and how to manage these conversations with patients and their family members. Both internal and external barriers remained after education, with nurses experiencing insecurity and fear, and a sense of being inhibited by the environment. However, they were more aware of the barriers after the education, and it was easier to find strategies to manage the conversations. They demonstrated support for each other in the team both before and after participating in the program.

SIGNIFICANCE OF RESULTS

The educational program gave nurses strategies for discussing existential issues with patients and family members. The knowledge that internal and external barriers impede communication should compel organizations to work on making conditions more conducive, for example, by supporting nurses to learn strategies to more easily manage conversations about existential issues and by reviewing the physical environment and the context in which they are conducted.

A critical incident study of ICU nurses during the COVID-19 pandemic

BACKGROUND

Intensive care unit nurses are providing care to COVID-19 patients in a stressful environment. Understanding intensive care unit nurses' sources of distress is important when planning interventions to support them.

PURPOSE

To describe Canadian intensive care unit nurse experiences providing care to COVID-19 patients during the second wave of the pandemic.

DESIGN

Qualitative descriptive component within a larger mixed-methods study.

PARTICIPANTS AND RESEARCH CONTEXT

Participants were invited to write down their experiences of a critical incident, which distressed them when providing nursing care. Thematic analysis was used to analyze the data.

ETHICAL CONSIDERATIONS

The study was approved by the ethics committee at the researchers' university in eastern Canada.

RESULTS

A total of 111 critical incidents were written by 108 nurses. Four themes were found: (1) managing the pandemic, (2) witness to families' grief, (3) our safety, and (4) futility of care. Many nurses' stories also focused on the organizational preparedness of their institutions and concerns over their own safety.

DISCUSSION

Nurses experienced moral distress in relation to family and patient issues. Situations related to insufficient institutional support, patient, and family traumas, as well as safety issues have left nurses deeply distressed.

CONCLUSION

Identifying situations that distress intensive care unit nurses can lead to targeted interventions mitigating their negative consequences by providing a safe work environment and improving nurses' well-being.

Professional experiences of formal healthcare providers in the provision of medical assistance in dying (MAiD): A scoping review

OBJECTIVE

This scoping review describes the existing literature which examines the breadth of healthcare providers' (HCP's) experiences with the provision of medical assistance in dying (MAiD).

METHOD

This study employed a scoping review methodology: (1) identify research articles, (2) identify relevant studies, (3) select studies based on inclusion/exclusion criteria, (4) chart the data, and (5) summarize the results.

RESULTS

In total, 30 papers were identified pertaining to HCP's experiences of providing MAiD. Fifty-three percent of the papers were from Europe (n = 16) and 40% of studies were from the USA or Canada (n = 12). The most common participant populations were physicians (n = 17) and nurses (n = 12). This scoping review found that HCPs experienced a variety of emotional responses to providing or providing support to MAiD. Some HCPs experienced positive emotions through helping patients at the end of the patient's life. Still other HCPs experienced very intense and negative emotions such as immense internal moral conflict. HCPs from various professions were involved in various aspects of MAiD provision such as responding to initial requests for MAiD, supporting patients and families, nursing support during MAiD, and the administration of medications to end of life.

SIGNIFICANCE OF RESULTS

This review consolidates many of the experiences of HCPs in relation to the provision of MAiD. Specifically, this review elucidates many of the emotions that HCPs experience through participation in MAiD. In addition to describing the emotional experiences, this review highlights some of the roles that HCPs participate in with relation to MAiD. Finally, this review accentuates the importance of team supports and self-care for all team members in the provision of MAiD regardless of their degree of involvement.

Registered nurses and undergraduate nursing students' attitudes to performing end-of-life care

Registered Nurses (RNs) are in the immediate position to provide End-of-life (EOL) care and counselling for patients and families in various settings. However, EOL-care often creates feelings of uncertainty and inadequacy linked to inexperience, lack of education, and attitude. To identify and describe factors associated with RNs' attitudes towards EOL-care, and to identify whether and how these attitudes differ from undergraduate nursing students' (UNSs) attitudes, a descriptive and comparative, quantitative study was performed. The FATCOD-instrument, focusing on attitude towards EOL-care, was used and the results analysed with descriptive and nonparametric statistics. In total, 287 RNs in 14 different specialist programmes, and 124 UNSs participated. A statistically significant difference (p = 0.032) was found in attitude towards EOL-care based on clinical experience. RNs in "Acute Care" and "Paediatric & Psychiatry Care" specialist programmes had a less positive attitude towards EOL-care (compared to RNs in other specialist programmes), while RNs attending the Palliative Care programme had the most positive attitudes. RNs and UNSs' scores differed statistically significantly in 17 out of 30 FATCOD variables. Finally, the results imply that there is a need for greater emphasis on further continuing education within EOL care for RNs working in all types of clinical specialities to encourage RNs talking about death and to enhance attitudes towards EOL care.

Communication about the desire to die: Development and evaluation of a first needs-oriented training concept - A pilot study

OBJECTIVE

Patients' desire to die (DD) is rarely discussed in palliative care (PC) due to health professionals' (HPs) feeling of uncertainty. The aim of the study was to develop and evaluate a training to increase HPs' self-confidence in responding professionally to patient's DD and to assess the feasibility of this approach.

METHODS

The training course was developed via focus groups and relevant literature and refined with an advisory board. An evaluation design was developed to evaluate training outcomes and to examine feasibility. To assess self-confidence, knowledge, skills, and attitudes: (1) standardized surveys were applied at T1 (before training), T2 (directly after), and T3 (3 months later), and were analyzed by descriptive and non-parametric statistics; and (2) participants' open feedback was summarized by content.

RESULTS

A two-day multi-disciplinary training was developed to improve self-confidence via diverse teaching methods. Twenty-four HPs from general and specialized PC were participated. Via self-rating on Likert scales at three time points, improvements were seen at T1, T2, and partly remained at T3, especially in the overall item of self-confidence in communicating with patients about their DD (means: 4.3. at T1, 5.7 at T2, and 5.9 at T3; on a 7-point scale with 1 = lowest value and 7 = highest value). Fewer improvements were found in skills (using different approaches) and attitudes (feeling less helplessness). Open feedback revealed a high appreciation for the training, especially the composition of participants, the role-play, and the overall increase of awareness of the topic.

SIGNIFICANCE OF RESULTS

The developed training on addressing DD meets a need and was perceived by the participants to be of added value. Future research should measure training effects with a validated instrument, including more participants, diverse participant groups, and a control group. Effects on patients should be assessed.

Being on the Frontline: Nurses' Experiences Providing End-of-Life Care to Adults With Hematologic Malignancies

The aim of this study was to explore the experiences of nurses providing end-of-life care to patients with hematologic malignancies, in a hematology oncology setting, in an acute general hospital. A qualitative hermeneutic phenomenological design was used, and 2 sets of semistructured interviews were conducted with 5 female nurses. The transcribed texts were analyzed using Interpretative Phenomenological Analysis. Two main themes emerged: "battling against medical futility" and "struggling with the emotional burden of care." Nurses perceived that the transfer of these patients at end of life to intensive critical care settings, coupled with the particularly aggressive treatments and corresponding symptom burden, prevented them from experiencing a dignified death. Consequently, nurses struggled with a gamut of emotions that included feelings of helplessness, distress, and compassion fatigue. Providing nursing care at end of life was perceived to be particularly challenging with the younger patients or with those who reminded them of family members. The findings highlight the unique challenges experienced by these nurses and the need to support them in their work with patients having hematologic malignancies at end of life within a well-resourced setting.

Educating the Existential View to Nurses in Cancer Care: A Review

Background:

The aim of this study was to review the interventional studies about educating existential concepts to the nurses working in cancer care.

Materials and Methods:

In this systematic narrative review, the papers published in English and Farsi databases of PubMed, Elsevier, web of since, Scopus, ProQuest, ERIC, Google Scholar and Ovid, MagIran and SID, from 1990 to 2018 were reviewed. Methodological quality of the studies was independently assessed by, using checklists developed by Greenhalgh, and Cochrane Center. No statistical pooling of the outcomes was performed, due to heterogeneity of the outcomes.

Results:

After wide search, the 17 studies entered to this narrative study. The results showed that educating the existential concept to the nurses dealing with cancer patients can improve their self-competency in providing efficient care to these patients and their ability in decision making. It also enhances their quality of life and decreases the death anxiety and emotional exhaustion.

Conclusions:

There were limited and low quality interventional studies about the effects of educating existential concepts to the nurses dealing with cancer patients. These studies showed that knowing this philosophy can help nurses to address caring needs of cancer patients more efficiently. The specific method or content of education cannot be recommended because of the large differences in the methodologies between the studies.

Tiredness of Life in Older persons: A Qualitative Study on Nurses’ Experiences of Being Confronted With This Growing Phenomenon

Background and Objectives

With worldwide aging it is imperative to understand nurses’ perceptions of tiredness of life (ToL) and their ways of dealing with an increasingly common phenomenon. Most research on ToL relates to older individuals’ experiences. This study aimed to gain insight into nurses’ (a) perceptions of, (b) attitude(s) toward, and (c) ways of dealing with ToL in older patients.

Research Design and Methods

Qualitative study with elements of constructivist grounded theory. Data were collected by means of semi-structured interviews between February 2016 and June 2017 with a purposive sample of 25 nurses working in home care and nursing homes.

Results

A careful consideration indicative of an oscillation between 3 levels (e.g., behavioral, cognitive, and affective) is present. The confrontation with persons having ToL instigates a cognitive process of searching to understand the state a person is in, which on its turn ensues in an emotional balancing between courage and powerlessness and a behavioral approach of action or dialogue.

Discussion and Implications

Our findings indicate that nurses aim to provide good care, sensitive to the older person’s needs, but this process is not without ambiguity. This study provides nurse managers with valuable guidance to (a) support nursing staff in dealing with ToL, and (b) advance opportunities for emotionally sensitive care and (individual- and team-based) reflection. Finally, this study offers suggestions for education programs to incorporate ToL in curricula.

Being disconnected from life: meanings of existential loneliness as narrated by frail older people

OBJECTIVES

This study illuminated the meanings of existential loneliness (EL) as narrated by frail older people.

METHOD

Data were collected through individual narrative interviews with 23 people 76-101 years old receiving long-term care and services. A phenomenological hermeneutical analysis was performed, including a naïve reading and two structural analyses as a basis for a comprehensive understanding of EL.

RESULT

Four themes were identified related to meanings of EL: (1) being trapped in a frail and deteriorating body; (2) being met with indifference; (3) having nobody to share life with; and (4) lacking purpose and meaning. These intertwined themes were synthesized into a comprehensive understanding of EL as 'being disconnected from life'.

CONCLUSION

Illness and physical limitation affects access to the world. When being met with indifference and being unable to share one's thoughts and experiences of life with others, a sense of worthlessness is reinforced, triggering an experience of meaninglessness and EL, i.e. disconnection from life. It is urgent to develop support strategies that can be used by health care professionals to address older people in vulnerable situations, thereby facilitating connectedness.

Nurses attitudes towards death, dying patients and euthanasia: A descriptive study

Background:

Attitudes of nurses towards death and related concepts influence end-of-life care. Determining nurses’ views and attitudes towards these concepts and the factors that affect them are necessary to ensure quality end-of-life care.

Objectives:

The purpose of this study was to determine nurses’ views and attitudes about death, dying patient, euthanasia and the relationships between nurses’ characteristics.

Methods:

Participants consist of the nurses who volunteered to take part in this descriptive study from 25 hospitals (n = 340) which has a paediatric or adult intensive care unit and located within the boundaries of Ankara, Turkey. ‘Nurse Information Form’ and ‘Attitude Scale about Euthanasia, Death and Dying Patients (DAS)’ were used as data collection tool.

Ethical consideration:

Written permissions were received from the ‘Noninterventional Clinical Researches Ethics Board’ of authors’ university and education councils of each hospital. Informed consent was obtained from participants.

Findings:

It is found that there are statistically significant difference among the factors of marital status, having a child, years of experience, bereavement experience, affected by working with dying patient, definition of euthanasia, views about patients who are appropriate for euthanasia, views about patients who desire to die and feeling need for counselling on these concepts according to the mean total score of nurses’ attitudes about euthanasia, death and dying patient (p < 0.05).

Conclusion:

The results indicate that nurses are negatively affected to face the concepts of death, euthanasia and work with dying patient. This is reflected in their attitude. In order to gain positive attitude towards death, dying patient and euthanasia, the implementation of training and consulting services to nurses at appropriate intervals during both education and professional life are required.

Tragedy in moral case deliberation

In healthcare practice, care providers are confronted with tragic situations, in which they are expected to make choices and decisions that can have far-reaching consequences. This article investigates the role of moral case deliberation (MCD) in dealing with tragic situations. It focuses on experiences of care givers involved in the treatment of a pregnant woman with a brain tumour, and their evaluation of a series of MCD meetings in which the dilemmas around care were discussed. The study was qualitative, focusing on the views and experiences of the participants. A case study design is used by conducting semi-structured interviews (N = 10) with health care professionals who both played a role in the treatment of the patient and attended the MCD. The results show that MCD helps people to deal with tragic situations. An important element of MCD in this respect is making explicit the dilemma and the damage, demonstrating that there is no simple solution. MCD prompts participants to formulate and share personal experiences with one another and thus helps to create a shared perception of the situation as tragic. The article concludes that MCD contributes to the sharing of tragic experiences, and fosters mutual interaction during a tragedy. Its value could be increased through explicit reflection on the aspect of contingency that characterises tragedy.

The caring encounter in nursing

BACKGROUND:

The concept 'encounter' occurs in caring literature as a synonym for dialogue and relation describing deeper levels of interaction between patient and nurse. In nursing and caring research, the concept 'caring encounter' is often used without further reflection on the meaning of the concept. Encounters are, however, continuously taking place in the world of caring, which calls for a clarification of the concept.

OBJECTIVES:

This study is an analysis of the concept of caring encounter in nursing from the patients' and nurses' point of view.

METHOD:

Rodgers' evolutionary view guided the concept analysis within the theoretical perspective of caritative caring.

DATA SOURCES:

Peer-reviewed articles in English published between 1990 and 2014 were retrieved from the databases: CINAHL, PubMed, Web of Science, ScienceDirect (Elsevier), Springer Link, Primo Central (Ex Libris) and Academic Search Premier (EBSCO) using different combinations of encounter, caring and nursing as keywords. In all, 28 articles related to caring encounters were included in the analysis after applying inclusion and exclusion criteria.

ETHICAL CONSIDERATIONS:

This study was conducted according to good scientific practice.

RESULTS:

Four antecedents to the caring encounter are found in the nurse's way of being: a reflective way of being; openness, sensitivity, empathy and ability to communicate; confidence, courage and professionalism; and showing respect and supporting dignity. The attributes are as follows: being there, uniqueness and mutuality. As a consequence, the caring encounter influences both patient and nurse.

DISCUSSION AND CONCLUSION:

The caring encounter is an encounter between two equal persons where one is nurse and the other is patient. They encounter in mutuality, in true presence, and both have allowed themselves to be the person they are. The results clarify the conceptual differences between relationship and caring communion as the mutuality in the caring encounter differs from the dependence on the other pronounced in the relationship.

Development of an existential support training program for healthcare professionals

Objective:

Our aim was to describe the developmental process of a training program for nurses to communicate existential issues with severely ill patients.

Method:

The Medical Research Council (MRC) framework for the development and evaluation of complex interventions was used to develop a training program for nurses to communicate about existential issues with their patients. The steps in the framework were employed to describe the development of the training intervention, and the development, feasibility and piloting, evaluation, and implementation phases. The development and feasibility phases are described in the Methods section. The evaluation and implementation phases are described in the Results section.

Results:

In the evaluation phase, the effectiveness of the intervention was shown as nurses' confidence in communication increased after training. The understanding of the change process was considered to be that the nurses could describe their way of communicating in terms of prerequisites, process, and content. Some efforts have been made to implement the training intervention, but these require further elaboration.

Significance of results:

Existential and spiritual issues are very important to severely ill patients, and healthcare professionals need to be attentive to such questions. It is important that professionals be properly prepared when patients need this communication. An evidence-based training intervention could provide such preparation. Healthcare staff were able to identify situations where existential issues were apparent, and they reported that their confidence in communication about existential issues increased after attending a short-term training program that included reflection. In order to design a program that should be permanently implemented, more knowledge is needed of patients' perceptions of the quality of the healthcare staff's existential support.