The specialist palliative care nurse: A qualitative study of the patients’ perspective

Role and contribution of the nurse in caring for patients with palliative care needs: A scoping review

BACKGROUND

The provision of high-quality palliative care is important to nursing practice. However, caring for palliative care patients and their families is challenging within a complex everchanging health environment. Nonetheless the caring, artistic role of the nurse is fundamental to the care of the patient and family. However, this role is currently being overshadowed by the technical and scientific elements of nursing.

METHODS

A scoping review was conducted utilising Arksey and O'Malley's framework to identify the role and contribution of nurses in caring for patients with palliative care needs. An open time period search of eight electronic databases (MEDLINE, CINAHL, Academic Search Complete, PsycINFO, EMBASE, Web of Science, Scopus and Cochrane Library) was conducted on the 8th of March 2023 and updated on the 30th of April 2024. Screening was performed independently by two reviewers against eligibility criteria with meetings between authors to discuss included papers and form a consensus. Data was extracted relating to palliative care nursing, methodology, key findings, and recommendations. The analysed and summarised data was mapped onto Oldland et al seven domains framework: (a) medical/nursing and technical competence, (b) person centred care, (c) positive interpersonal behaviours, (d) clinical leadership and governance, (e) promotion of safety, (f) management of the environment, and (g) evidence-based practice.

RESULTS

Fifty-five papers met the criteria for this review which describes the role and contribution of nurses in caring for palliative patients across all domains of professional practice. The review found the leading areas of nurse contribution were person centred, interpersonal and nursing care aspects, with leadership, managing the environment, patient safety and evidence-based practice evident but scoring lower. The contribution of the nurse in palliative care supports a biopsychosocial-educational approach to addressing the physical, emotional and social needs of patients with palliative care needs and their families across the care continuum.

CONCLUSION

Nurses in palliative care engage in a wide range of roles and responsibilities in caring for patients and their families with palliative care needs. However, there remains minimal evidence on the assessment, intervention, and evaluation strategies used by nurses to highlight the importance of their role in caring for patients and their families in this area. The findings of this review suggest that the artistic element of nursing care is being diluted and further research with a focus on evidencing the professional competence and artistic role of the nurse in the provision of palliative care is required. In addition, research is recommended that will highlight the impact of this care on patient and family care outcomes and experiences.

[Advanced nursing practice model for head and neck cancer: A practice development project]

Advanced nursing practice model for head and neck cancer: A practice development project Abstract. Background: Head and neck cancer confronts patients and their families with big challenges due to complex treatments as well as changes in vital functions and appearance. They require multifaceted support and benefit from coordinated, interprofessional collaboration and advanced nursing practice. Problem/aim: In a tertiary head and neck cancer center, a coordinating contact person was missing for patients, families and the care team. Therefore, a project was launched to develop an advanced nursing practice program. Methods: Methods included an advanced nursing practice concept, approaches for practice development, and action research. The project consisted of four phases: Stakeholder analysis and literature review were followed by the definition of the advanced nursing practice program, which was then tested during a pilot phase, and evaluated using structural/process data and stakeholder interviews. Results: Evidence-based, continuous, person-centered care was improved across the care continuum for patients/families. The nurses' expertise was supported and the collaboration with internal/external clinicians was facilitated. Patients/families valued the continuity offered by the advanced practice nurse. Discussion: The methodological approaches supported a goal-oriented approach; especially participatory practice development helped to address employees' concerns. Limitations/transfer: To date, a sustainable program cannot yet be warranted. For similar projects, an approach with stakeholder analysis, multidisciplinary focus, and early evaluation planning is recommended.

[Care provided by an advanced practice nurse: Experiences of patients with sarcoma and family members. A qualitative study]

Care provided by an advanced practice nurse: Experiences of patients with sarcoma and family members. A qualitative study Abstract. Background: Sarcomas are a rare, heterogeneous group of malignant tumors with different trajectories, which cause significant burden to patients and families. Due to the complex nature of treatment, an interprofessional team at the sarcoma center of a Swiss university hospital provides care to affected individuals. This interprofessional team includes an advanced practice nurse (APN) who cares for patients and family members throughout the trajectory of the disease. To date, there are limited descriptions within literature of APN care from the perspective of patients with sarcoma and their family members. Aim: To investigate how patients with sarcoma and their family members experienced APN care. Methods: The study was guided by the qualitative research methodology "Interpretive Description". Individual interviews with seven patients and five family members were conducted and analyzed in an iterative process. Results: For patients and family members, the time from diagnosis to therapy and follow-up was very stressful. They experienced the APN's care during this time as a great support and described her as a compassionate, trustworthy and continuous contact person who expertly provided information and advice while acting as a coordinator. Conclusions: Patients with sarcoma and their family members require continuous contact with a person who is compassionate, while also professional, confident and competent. Providing APN care can meet all of these essential requirements.

Integrated palliative care networks from the perspectives of patients: A cross-sectional explorative study in five European countries

BACKGROUND:

Although examining perspectives of patients on integrated palliative care organisation is essential, available literature is largely based on administrative data or healthcare professionals’ perspectives.

AIM:

(1) Providing insight into the composition and quality of care networks of patients receiving palliative care and (2) describing perceived integration between healthcare professionals within these networks and its association with overall satisfaction.

DESIGN:

Cross-sectional explorative design.

SETTING/PARTICIPANTS:

We recruited 157 patients (62% cancer, 25% chronic obstructive pulmonary disease, 13% chronic heart failure, mean age 68 years, 55% female) from 23 integrated palliative care initiatives in Belgium, Germany, the United Kingdom, Hungary and the Netherlands.

RESULTS:

About 33% reported contact with a palliative care specialist and 48% with a palliative care nurse. Relationships with palliative care specialists were rated significantly higher than other physicians (p < 0.001). Compared to patients with cancer, patients with chronic obstructive pulmonary disease (odds ratio = 0.16, confidence interval (0.04; 0.57)) and chronic heart failure (odds ratio = 0.11, confidence interval (0.01; 0.93)) had significantly lower odds of reporting contact with palliative care specialists and patients with chronic obstructive pulmonary disease (odds ratio = 0.23, confidence interval (0.08; 0.71)) had significantly lower odds of reporting contact with palliative care nurses. Perceptions of main responsible healthcare professionals or caregivers in patient’s care networks varied across countries. Perceived integration was significantly associated with overall satisfaction.

CONCLUSION:

Palliative care professionals are not always present or recognised as such in patients’ care networks. Expert palliative care involvement needs to be explicated especially for non-cancer patients. One healthcare professional should support patients in understanding and navigating their palliative care network. Patients seem satisfied with care provision as long as continuity of care is provided.

Nurses respond to patients' psychosocial needs by dealing, ducking, diverting and deferring: an observational study of a hospice ward

BACKGROUND

Psychosocial support is considered a central component of nursing care but it remains unclear as to exactly how this is implemented in practice. The aim of this study was to provide a descriptive exploration of how psychosocial needs (PNs) of patients in a hospice ward are expressed and met, in order to develop an understanding of the provision of psychosocial support in practice.

METHODS

An embedded mixed-methods study was conducted in one hospice ward. Data collection included observations of patients' expressions of PNs and nurses' responses to those expressed PNs, shift hand-overs and multi-disciplinary meetings. Interviews about the observed care were conducted with the patients and nurses and nursing documentation pertaining to psychosocial care was collated. Descriptive statistical techniques were applied to quantitative data in order to explore and support the qualitative observational, interview and documentary data.

RESULTS

During the 8-month period of observation, 227 encounters within 38 episodes of care were observed among 38 nurses and 47 patients. Within these encounters, 330 PNs were expressed. Nurses were observed immediately responding to expressed PNs in one of four ways: dealing (44.2 %), deferring (14.8 %), diverting (10.3 %) and ducking (30.7 %). However, it is rare that one type of PN was clearly expressed on its own: many were expressed at the same time and usually while the patient was interacting with the nurse for another reason, thus making the provision of psychosocial support challenging. The nurses' response patterns varied little according to type of need.

CONCLUSIONS

The provision of psychosocial support is very complex and PNs are not always easily recognised. This study has allowed an exploration of the actual PNs of patients in a hospice setting, the way in which they were expressed, and how nurses responded to them. The nurses faced the challenge of responding to PNs whilst carrying out the other duties of their shift, and the fact that nurses can provide psychosocial support as an inherent component of practice was verified. The data included in this paper, and the discussions around the observed care, provides nurses everywhere with an example against which to compare their own practice.

Development of a questionnaire to measure the key attributes of the community palliative care specialist nurse role

BACKGROUND

Recent worldwide economic events have forced an examination of the nurse's contribution to high-quality, effective, person-centred care. Since the role of specialist nurses is considered one of the least understood or valued developments in nursing, specialist nurses must demonstrate their contribution to quality, person-centred health care.

AIM

To develop a questionnaire which aims to measure the quality of care provided by palliative care specialist nurses from the patients' perspective and to undertake initial validation.

METHOD

The process of questionnaire development involved six phases including systematic literature reviews, patient advisory groups and expert panel reviews, each of which contributed to the questionnaire face and content validity. Johnston's Expert Palliative Care Nurse Model (2002; 2005) provided an evidence-based framework for the development of the questionnaire, and enabled the identification of the key attributes of the palliative care specialist nurse role, thereby providing the themes on which to base the questionnaire.

RESULTS

The Quality Measure for Palliative Nursing, a questionnaire, was developed. The themes identified in the questionnaire--personal characteristics, communication skills, knowledge, relationship with patient and providing comfort--aim to facilitate measurement of the quality of care provided by palliative care specialist nurses. Designed for use by palliative patients the Quality Measure for Palliative Nursing is a one-page questionnaire comprising of 15 questions.

CONCLUSIONS

The Quality Measure for Palliative Nursing is unique since it aims to measure the quality of care provided by community palliative care specialist nurses, and could also be used to measure patient satisfaction with the quality of care provided. Further testing is recommended to ensure that this questionnaire can provide reliable and valid results.

Case management in primary palliative care is associated more strongly with organisational than with patient characteristics: results from a cross-sectional prospective study

BACKGROUND

Case managers have been introduced in Dutch primary palliative care; these are nurses with expertise in palliative care who offer support to patients and informal carers in addition to the care provided by the general practitioner and home care nurses. This study aims to describe support and investigate what characteristics of patients and the organizational setting are related to the number of contacts and to the number of times topics are discussed between the case manager and patients and/or informal carers.

METHODS

Prospective study following cancer patients (n = 662) receiving support from a palliative care case manager in Dutch primary care, using registration forms filled out by the case manager after contact with the patient and/or informal carer. In backward linear regression, the association was studied between patient or organizational characteristics and the number of contacts and the number of times conversation topics were discussed.

RESULTS

Organizational characteristics add more to explained variability in data than patient characteristics. Case managers provide support in a flexible manner with regard to the number, mode, persons present, and duration of contacts. Support covered all domains of palliative care, with most attention given to physical complaints, life expectancy and psychological aspects.

CONCLUSIONS

Support offered by the case managers is prompted by characteristics of the organization for which they work. This is contradictory to the idea of patient centered care highly valued in palliative care.

The role and organisation of community palliative specialist nursing teams in rural England

This article describes a study that used a qualitative approach, purposive sampling and semi-structured telephone interviews conducted with specialist palliative care nurses from six rural community teams in England. The study investigated how services were organised and the issues of delivering specialist palliative nursing care in a rural area. Qualitative content analysis was used to analyse the data. The findings showed many similarities in that the majority of patients in rural areas were not accessing hospice services and there was a greater reliance on care at home. However, the challenges in delivering care ranged from managing patient expectations, geographical distance, lack of technology to support remote working and education for the specialist palliative care teams. The study makes specific recommendations for rural community specialist palliative care teams.

An exploration of self-management support in the context of palliative nursing: a modified concept analysis

Background

The role of self-management is often ambiguous, yet, it is an important area in clinical practice for palliative nurses. A clear conceptual understanding, however, of what it represents is lacking.

Method

This paper reports an analysis of the concept of self-management support in palliative nursing.

Avant and Walker’s method was used to guide this concept analysis.

A search of electronic databases (1990–2013), use of internet search engines and supplementary hand searching produced an international data set of reviews, empirical research, editorials, protocols and guidelines.

Results

Based on the analysis self-management support in palliative nursing has been defined as assessing, planning, and implementing appropriate care to enable the patient to live until they die and supporting the patient to be given the means to master or deal with their illness or their effects of their illness themselves.

Conclusions

Clarity with the concept of self-management support and palliative nursing could enable nurses to provide more patient and family centred care to people facing life threatening illnesses.

Nurse-led follow-up at home vs. conventional medical outpatient clinic follow-up in patients with incurable upper gastrointestinal cancer: a randomized study

CONTEXT

Upper gastrointestinal cancer is associated with a poor prognosis. The multidimensional problems of incurable patients require close monitoring and frequent support, which cannot sufficiently be provided during conventional one to two month follow-up visits to the outpatient clinic.

OBJECTIVES

To compare nurse-led follow-up at home with conventional medical follow-up in the outpatient clinic for patients with incurable primary or recurrent esophageal, pancreatic, or hepatobiliary cancer.

METHODS

Patients were randomized to nurse-led follow-up at home or conventional medical follow-up in the outpatient clinic. Outcome parameters were quality of life (QoL), patient satisfaction, and health care consumption, measured by different questionnaires at one and a half and four months after randomization. As well, cost analyses were done for both follow-up strategies in the first four months.

RESULTS

In total, 138 patients were randomized, of which 66 (48%) were evaluable. At baseline, both groups were similar with respect to clinical and sociodemographic characteristics and health-related QoL. Patients in the nurse-led follow-up group were significantly more satisfied with the visits, whereas QoL and health care consumption within the first four months were comparable between the two groups. Nurse-led follow-up was less expensive than conventional medical follow-up. However, the total costs for the first four months of follow-up in this study were higher in the nurse-led follow-up group because of a higher frequency of visits.

CONCLUSION

The results suggest that conventional medical follow-up is interchangeable with nurse-led follow-up. A cost utility study is necessary to determine the preferred frequency and duration of the home visits.

Understanding the experience of patients with chronic obstructive pulmonary disease who access specialist palliative care: a qualitative study

BACKGROUND

Palliative care for people with life-limiting non-malignant disease is increasingly prioritised. People with end-stage chronic obstructive pulmonary disease are among a key group of non-cancer patients likely to benefit from specialist palliative care, but it remains uncertain whether the needs of this group are met by existing services.

AIM

To evaluate the experiences of patients with chronic obstructive pulmonary disease who accessed specialist palliative care.

DESIGN

Data from semi-structured interviews were analysed using a hermeneutic phenomenological approach.

SETTING/PARTICIPANTS

Eight patients accessing specialist palliative care within one city in North West England.

RESULTS

Perceived benefits of specialist palliative care included reduced frequency of hospital admission, improved physical and psychological symptoms, reduced social isolation and a broadened physical environment. Participants were mainly aware of their poor prognosis, but discussion of referral to palliative care sometimes caused distress owing to the historical associations between dying and hospice care. Following engagement with services, participants' perceptions changed: palliative care was associated with social inclusion and opportunities to engage in reciprocal and altruistic social action. Negative associations were replaced by uncertainty and anxiety about the prospect of discharge.

CONCLUSIONS

Much within existing services works well for people with chronic obstructive pulmonary disease, but opportunities to enhance palliative care for this underserved group remain. Future research might focus on prospectively evaluating the impact of key components of palliative care on core patient-centred outcomes. Additionally, work must be done to raise awareness of the benefits of specialist palliative care for non-cancer patients, as negative associations can form a barrier to access.

Do patients die well in your emergency department?

OBJECTIVES

Although the role of the ED in the management of patients needing palliative care is recognised internationally, there are little Australasian data on this issue. This study aimed to determine the current knowledge and attitude to the provision of palliative care in Australasian EDs.

METHODS

All ED directors in Australasia were invited to complete an online survey about the provision of palliative care in their department. Quantitative data were described using counts and proportions, and qualitative data were summarised thematically.

RESULTS

Of 165 eligible ED directors, 35 completed the survey (22%; 95% CI, 15-28%). Only 17/35 (49%; 95% CI, 32-65%) believed that ED provided good palliative care, and 28/35 (80%; 95% CI, 67-93%) were unaware of international gold standard palliative care protocols. Most had access to hospital-based palliative care specialists 27/35 (77%; 95% CI, 63-91%); however, only 5/27 (19%; 95% CI, 4-33%) used them. Few EDs undertake formal training in palliative care 10/35 (29%; 95% CI, 16-45%). Respondents showed concern about the quality of palliative care they provide and advocated for more palliative care training.

CONCLUSION

Although limited by the low response rate, this survey indicates that there is a need and a desire for greater integration of the values and standards of high-quality palliative care in Australasian EDs.

Diversity in defining end of life care: an obstacle or the way forward?

Aim

The terms used to describe care at the end of life (EoL), and its definitions, have evolved over time and reflect the changes in meaning the concept has undergone as the field develops. We explore the remit of EoL care as defined by experts in EoL care, from across Europe and beyond, to understand its current usage and meanings.

Method

A qualitative survey attached to a call for expertise on cultural issues in EoL care was sent to experts in the field identified through the literature, European EoL care associations, and conferences targeted at EoL care professionals. Respondents were asked to identify further contacts for snowball recruitment.The responses were analysed using content and discourse analysis.

Results

Responses were received from 167 individuals (33% response rate), mainly from academics (39%) and clinical practitioners working in an academic context (23%) from 19 countries in Europe and beyond. 29% of respondents said explicitly that there was no agreed definition of EoL care in practice and only 14% offered a standard definition (WHO, or local institution). 2% said that the concept of EoL care was not used in their country, and 5% said that there was opposition to the concept for religious or cultural reasons. Two approaches were identified to arrive at an understanding of EoL care: exclusively by drawing boundaries through setting time frames, and inclusively by approaching its scope in an integrative way. This led to reflections about terminology and whether defining EoL care is desirable.

Conclusion

The global expansion of EoL care contributes to the variety of interpretations of what it means. This complicates the endeavour of defining the field. However, when diversity is taken seriously it can open up new perspectives to underpin the ethical framework of EoL care.

Tolstoy, stories, and facilitating insight in end of life care: exploring ethics through vicarious experience

Facilitating moral insight in end of life care can be challenging, and the purpose of this paper is to illustrate how this can be nurtured by means of creative literature. Tolstoy's Death of Ivan Ilych is presented as an example of such literature. Aristotle's Nichomean Ethics provides the philosophical underpinning for the method used. Sources also include the nursing literature, and students' evaluations of the impact of Tolstoy's novella on their ability to perceive the ethical issues arising in end of life care. Comments from evaluations were analysed and significant themes emerged. Students' comments clearly support the suggestion that use of this novella has facilitated insight into ethical issues at the end of life. Evaluations also indicate that vicarious experience gained through reading this novella has helped to nurture sensitivity and professional insight into the importance of compassion and offering 'comfort' to the dying person.

On the meanings and experiences of living and dying in an Australian hospice

Drawing on qualitative interviews with patients near death, in this article we explore people’s experiences of living and dying in a hospice in-patient unit. The results illustrate the tensions and complexities of entering into the hospice environment and how its character (i.e. people, interactions and spaces) shapes experiences near death.The results illustrate the hospice in-patient unit as playing a vitally important role in supporting the end of life, but also, the unique challenges this environment presents to individual well-being. Key themes emergent from the interviews were: loss of self and identity nostalgia; liminality and the home/help dialectic; and the performative elements of dying. To explore and unpack these processes, we draw together different facets of previous conceptual work in sociology, working towards a more nuanced conceptualization of the in-patient hospice experience.

A critical review of the evidence for nurses as information providers to cancer patients

AIMS

To review evidence on the role of oncology nurses in the provision of information to cancer patients and to delineate evidence-based implications for clinical practice and research.

BACKGROUND

Provision of information is central for the empowerment of patients to participate in their care. There is not enough evidence regarding the nursing role in the information delivery process in cancer patients.

DESIGN

Descriptive literature review.

METHODS

From January 1990-2008, databases searched included Medline, CINAHL, PubMed, CancerLit and the Cochrane Library. Original research articles addressing the role of nurses in information delivery were included. We explored evidence on: (1) the effectiveness of nurses as information providers, (2) the way patients evaluate nurses' input to information delivery, (3) the extent to which nurses contribute to information delivery to cancer patients and (4) the types of information provided by nurses.

RESULTS

The most important findings were: (1) nurses' role as information providers for cancer patients is prominent, especially after the initiation of treatment, (2) specialist nurses are very effective in providing information, (3) no clear evidence exists on how nurses compare with other health-care professionals as information providers and (4) some evidence exists that patients may prefer nurses as information providers at specific times in their treatment and especially in regards to symptom management.

CONCLUSION

Well-designed studies provide some evidence that nurses are effective as information providers to cancer patients. Specifically, oncology nurses are able to provide information of both high quality and of appropriate quantity and to assist individuals to interpret information provided by others.

RELEVANCE TO CLINICAL PRACTICE

Oncology nurses should be specifically educated and prepared to offer explicit, practical and timely information and they should be trained in interpersonal communication skills, which will increase their ability to comprehend patient information needs.

Providing care and sharing expertise: Reflections of nurse-specialists in palliative home care

Objective:

This study explored the experiences, perspectives, and reflections of five nurse-specialists in palliative home care, whose dual role includes caring for patients in their daily practice as well as sharing their knowledge, skills, expertise, and experiences with other home care nurses in the community.

Methods:

A qualitative research design, incorporating face-to-face semistructured interviews, was used. Interviews were based on open-ended questions such as: “What is your experience in providing palliative home care to patients and their families? How do you feel about sharing your expertise and experiences with home care nurses?” Data were content analyzed using the constant comparative method.

Results:

Three major themes and a number of subthemes emerged: (1) acknowledging one's own limitations and humanness: (a) calling for backup, (b) learning as we go along, (c) coping with emotional demands, and (d) interacting with family members; (2) building a collaborative partnership: (a) working collaboratively, (b) sharing information, (c) guiding home care nurses, and (d) being nonjudgmental; and (3) teamwork and implementing palliative home care teams.

Significance of results:

Nurse-specialists play a key role in palliative home care as both carers and as resources of expert knowledge for other home care nurses caring for palliative patients. As the population ages, the health care system will be faced with increasing requests for high-quality palliative home care. The results of this study demonstrate that, from the perspective of the nurse-specialists of NOVA-Montréal (a nonprofit social and health service organization), nurse-specialists can work collaboratively with home care nurses to improve patients' quality of care and their quality of life. Moreover, patients and their families would benefit from the more widespread establishment of palliative care teams within community health organizations.

Exploration of communicative patterns of consultations in palliative cancer care

Building on the research conducted on institutional communication, and the analysis of actual communication taking place in clinical settings, this study describes and highlights features of palliative care consultations and focuses on the distribution of discursive space (i.e., share of words, lengths of turns), occurring topics and conversational frames. Six consultations between physicians, patients and significant others were videotaped and all participants took part in audio-taped interviews. The recordings were transcribed and analysed in regard to expectations of, the discursive space of, and topics addressed in the consultations. The distribution of the discursive space was unequal; the physicians had the greatest share of words and length of turns in all six consultations, and they mostly initiated discussion of medical issues connected to examinations and treatment, while only patients initiated the topic of the patient's future. During the consultations, institutional framing tended to dominate over client framing. There was found to be room for further study of the structure and content of palliative care consultations with emphasis on how the voice of the patient can manifest itself within the framework of the medical agenda of the consultation and its significance for palliative cancer team work.