End of life care in nursing homes: Translating focus group findings into action

Psychosocial burdens in palliative care - a longitudinal cohort study in nursing homes and impacts of the COVID-19 pandemic

BACKGROUND

In Germany, palliative care in nursing homes is becoming increasingly important. Simultaneously, nursing homes are particularly affected by the COVID-19 pandemic due to their vulnerable residents leading to increased burdens for nursing staff. Although a separate unit for palliative care may not be present in nursing homes as it is in, e.g., hospitals, palliative care occupies a large portion of the workday in nursing homes. As no study addressing this topic could be found, this study focused on the research questions of how the psychosocial burdens faced by nursing staff in palliative care have been affected by the COVID-19 pandemic and how those burdens differ from the psychosocial burdens encountered in general care.

METHODS

Basen on a longitudinal cohort study design, a total of 113 nurses, nursing assistants and caregivers drawn from two nursing homes in North Rhine-Westphalia, Germany, were surveyed pre-pandemic in 2019 and during the pandemic in 2022 using the Copenhagen Psychosocial Questionnaire (COPSOQ) III. Data were examined descriptively following the standardised COPSOQ procedure. Additionally, chi-squared test was conducted to investigate the homogeneity between the groups. Mean differences (MD) were provided and Cohen's d was calculated to evaluate relevant differences in psychosocial burdens between 2019 and 2022. In a second step, t-tests were performed to test statistical significance.

RESULTS

Relevant positive changes could be identified in 'Quantitative demands' (d = 0.321; MD = 5.9), 'Influence at work' (d = 0.244; MD = 5.4), 'Job insecurity' (d = 0.321; MD = 6.5), 'Insecurity over working conditions' (d = 0.296; MD = 6.8), 'Burnout symptoms related to residents' (d = 0.201; MD = 3.8), 'Degrees of freedom' (d = 0.455; MD = 9.6) and 'Presenteeism' (d = 0.425; MD = 11.8). Relevant negative changes were found in 'Dissolution' (d = 0.217; MD = 5.4; i.e., setting boundaries between work and private life), 'Role conflicts' (d = 0.282; MD = 5.5), 'Role clarity' (d = 0.251; MD = 3.3) and 'Burnout symptoms related to relatives' (d = 0.318; MD = 6.0). Relevant changes that were statistically significant according to the t-test could be identified in 'Degrees of freedom' (t-value=-2.40; p = 0.018) and 'Presenteeism' (t-value = 2.26; p = 0.026). Responses to questions concerning nursing homes' handling of the COVID-19 pandemic exhibited a mean score of 68.2 for 'Organisation/communication' and a mean score of 78.1 concerning 'Operational measures and overall assessment' during the COVID-19 pandemic.

CONCLUSIONS

Besides negative changes during the COVID-19 pandemic, some categories showed more positive results. The burdens of palliative care in nursing homes may be perceived differently than those of general care in nursing homes. Furthermore, the results indicate that perceptions of challenges in palliative care in nursing homes during the pandemic seem to be highly dependent on organisational working conditions and support that can strengthen the individual resources and resilience of the staff.

Registered Nurses’ Experiences of End-of-Life Care in Nursing Homes of South Korea: A Qualitative Study

This study aimed to qualitatively describe how registered nurses (RNs) experienced and perceived end-of-life (EOL) care for older residents in South Korean nursing homes. The participants included 11 nurses with experience of providing EOL care for older residents in six nursing homes. Data were collected through one-on-one in-depth interviews using semi-structured questions from 27 December 2019 to 22 October 2020. Around 1–2 interviews were conducted for each participant, and each interview lasted between 40 min and two hours. The interview data were analyzed using qualitative content analysis. Eight sub-themes were identified and abstracted under three themes: (a) “feeling fulfilled for doing my best until the last day,” (b) “defensive coping due to legal and institutional limitations,” and (c) “requirements for effective EOL care.” This study suggests that there are many challenges and issues regarding EOL care at nursing homes. In order to provide effective EOL care to older residents, the foundation of the EOL care system, as well as skills training, should be strengthened. Furthermore, securing qualified nursing manpower and achieving institutional improvement by reducing obstacles are warranted.

Quality of collaboration and information handovers in palliative care: a survey study on the perspectives of nurses in the Southwest Region of the Netherlands

Background

When patients receiving palliative care are transferred between care settings, adequate collaboration and information exchange between health care professionals is necessary to ensure continuity, efficiency and safety of care. Several studies identified deficits in communication and information exchange between care settings. Aim of this study was to get insight in the quality of collaboration and information exchange in palliative care from the perspectives of nurses.

Methods

We performed a cross-sectional regional survey study among nurses working in different care settings. Nurses were approached via professional networks and media. Respondents were asked questions about collaboration in palliative care in general and about their last deceased patient. Potential associations between quality scores for collaboration and information handovers and characteristics of respondents or patients were tested with Pearson’s chi-square test.

Results

A total of 933 nurses filled in the questionnaire. Nurses working in nursing homes were least positive about inter-organizational collaboration. Forty-six per cent of all nurses had actively searched for such collaboration in the last year. For their last deceased patient, 10% of all nurses had not received the information handover in time, 33% missed information they needed. An adequate information handover was positively associated with timeliness and completeness of the information and the patient being well-informed, not with procedural characteristics.

Conclusion

Nurses report that collaboration between care settings and information exchange in palliative care is suboptimal. This study suggests that health care organizations should give more attention to shared professionalization towards inter-organizational collaboration among nurses in order to facilitate high-quality palliative care.

[Palliative Care from the Perspective of Providers of General and Specialised Palliative Care - A Cross-Sectional Survey]

BACKGROUND

Palliative care is a particular challenge in rural regions with low population density. Every patient should have access to palliative care regardless of age, diagnosis, prognosis, place of residence and economic aspects. The aim was to identify problem areas in palliative care in rural regions and to find possible solutions from the perspective of health service providers.

METHODS

A standardised written survey was conducted among providers of general and specialised palliative care in the federal state of Mecklenburg-Western Pomerania. In total, 489 service providers were sent a questionnaire. A random sample of general palliative care providers and all specialised palliative care providers in Mecklenburg-Western Pomerania were contacted. For the evaluation of the structure of palliative care and to identify problem areas, the German school grading system was used (1=very good, 6=insufficient). The results of the survey were descriptively analysed.

RESULTS

The response rate was 19% (n=93). Identified problems were the interface between outpatient and inpatient care as well as between general and specialised palliative care. The cooperation between specialised outpatient palliative care teams and hospital with a palliative care unit was rated with an average of 1.9. The cooperation between specialised outpatient palliative care teams and hospitals without a palliative care unit was rated with an average of 3.6. The knowledge of palliative care of nurses in nursing homes was graded 4.0; 54.8% (n=51) of the participants could consider providing telemedicine care to palliative patients in addition to conventional care. The establishment of a palliative care coordination unit was rated as highly important by 34.4% of the participants.

CONCLUSIONS

The results indicate infrastructural, organisational and quality-related problems in providing palliative care. The provision of palliative care in rural areas could be strengthened through targeted training, outpatient consultation services, coordination units and the integration of telemedicine functionalities.

The Experience to Implement Palliative Care in Long-term Care Facilities: A Grounded Theory Study of Caregivers

PURPOSE

The purpose of this study was to explore the experiences of caregivers in long-term care facilities as they implement palliative care. Although palliative care has been available in Taiwan for more than 30 years, it is often provided in hospitals, few models in the long-term care facilities.

METHODS

Semi-structured interviews using grounded theory methodology and purposive sampling. Two small long-term care facilities that had performed well in palliative care were selected from eastern Taiwan. A total of 12 caregivers participated in in-depth semi-structured face-to-face interviews.

RESULTS

Four major stages in the implementation of palliative care were identified: (1) feeling insecure, (2) clarifying challenges, (3) adapting to and overcoming the challenges, and (4) comprehending the meaning of palliative care. The core category of these caregivers as "the guardians at the end of life" reflects the spirit of palliative care.

CONCLUSION

This study demonstrates that successful palliative care implementation would benefit from three conditions. First, the institution requires a manager who is enthusiastic about nursing care and who sincerely promotes a palliative care model. Second, the institution should own caregivers who possess personality traits reflective of enthusiasm for excellence, unusual ambition, and a true sense of mission. Third, early in the implementation phase of the hospice program, the institution must have the consistent support of a high-quality hospice team.