Nurses' responses to requests for forgiveness at the end of life

Meaning of Life Therapy: A Pilot Study of a Novel Psycho-Existential Intervention for Palliative Care in Cancer

Intervention in Palliative Care aims to provide physical, psychosocial, and spiritual relief for patients and family members. Brief interventions with a psycho-existential approach have shown positive responses; however, cultural adaptations are needed. This pilot study aimed to develop the Meaning of Life Therapy (MLT), a novel psycho-existential intervention, rooted in the Dignity Therapy, Life Review, and Meaning-Centered Psychotherapy. MLT was culturally adapted to the Portuguese context to include questions about forgiveness, apology, reconciliation, farewell, and a legacy document, i.e., the Life Letter. Nine PC cancer patients answered a 14-question MLT protocol, intended to help patients find purpose and meaning in life. Eight themes emerged: Family, Preservation of Identity, Life Retrospective, Clinical Situation, Achievements, Socio-Professional Valorization, Forgiveness/Apology/Reconciliation, and Saying Goodbye. MLT has proved its ability to respond to the psycho-existential needs of PC patients. Further studies should be conducted to gain extensive knowledge of the effectiveness of culturally responsive interventions.

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.

A Systematic Review and Narrative Synthesis of the Evidence Underpinning Theoretical Perspectives and Cultural Influences on Forgiveness in Palliative Care

Background: The process of forgiveness is proposed to reduce patient and family conflict and suffering in the face of life-limiting illness. However, it is unclear which theoretical perspectives underpin the concept of forgiveness in palliative care, and how culture may influence it. Objectives: To identify and synthesize primary evidence that underpins the concept of forgiveness within palliative care, and identify theoretical perspectives, including cultural assumptions. Design: A systematic review of studies on forgiveness in palliative care regardless of design was prospectively registered on PROSPERO. Narrative synthesis was conducted and the modified Seven-Point Checklist and modified Status Assessment Tool applied to appraise study quality (level 1) and contributions to theory building (level 2). Data Sources: Reference chaining and hand-searching were conducted for 10 electronic databases from 1960 to June 30, 2020. Results: Thirty-nine studies were included. Seven provided a definition of forgiveness, and six studies reported a process model. Twelve patient studies scored "high" on quality level 1 and nine scored "high" on level 2. Conceptualization of forgiveness included a conscious decision to abandon negative thoughts, feelings, and behaviors associated with conflicts, to find positive outcomes through processing of negative affect and cognitive reframing of conflicts. The process of forgiveness develops through time paralleled by an attributional movement from an external to an internal locus of control. Theoretical perspectives of systems, exchange and choice, social constructionism, behaviorism, and humanism were identified. Cultural contexts impact forgiveness. Conclusion: The synthesized model is based on primary evidence of mixed quality. Future research needs better theoretical conceptualization utilizing cultural perspectives. Forgiveness interventions with consideration of cultural influences are encouraged.

The Efficacy of a Forgiveness Bibliotherapy: A Randomized Controlled Trial with Nursing Students

Purpose of study: The need for forgiveness education for nursing self-care and forgiveness facilitation has risen. Therefore, the present pilot study tested the efficacy of an 8-week forgiveness bibliotherapy with a small number of undergraduate nursing students. Design of study: Matched pairs of nursing students were randomly assigned to either the experimental group or no-contact control group. The experimental group, using 8 keys to forgiveness by R. Enright (2015) as the treatment manual, read one chapter a week for 8 weeks and provided weekly reflections. Forgiveness and forgiveness-related outcome measures were administered at pretest, posttest, and one-month follow-up. Findings: At the posttest, the experimental group had significantly greater improvement in forgiveness compared to the control group with a large effect size, which was maintained at one month follow-up. There was no other significant difference between the two groups. Within-group comparisons of the experimental group showed improvement in forgiveness, anxiety, depression, and fatigue from pre to post testing periods and forgiveness, anger, anxiety, depression, and fatigue from pre to follow-up testing periods. Conclusion: Use of bibliotherapy may be a cost-effective way to promote the virtue of forgiveness for students in nursing programs.

Spiritual AIM: assessment and documentation of spiritual needs in patients with cancer

The chaplain is an essential member of the palliative care (PC) team, yet, standard methods to document chaplain assessments are lacking. The study team performed a retrospective analysis of chaplaincy documentation in an outpatient PC clinic at an academic medical center over 6 months (April 2017 to October 2017). The study team identified unique adult patients with cancer, then manually extracted variables from the electronic medical record. The primary objective was to assess the number of spiritual assessments documented by the chaplain. Secondary objectives included descriptive analysis of identified spiritual needs. Out of the 376 total patient encounters, 292 (77.8%) included documentation of a chaplain's spiritual assessment. The most frequent spiritual need was self-worth/community (n = 163, 55.8%).This study demonstrates that chaplains can effectively document Spiritual AIM-based screening and assessment. Moreover, this may be an effective documentation method across institutions to facilitate chaplain-based data.

Forgiveness facilitation in palliative care: a scoping review

OBJECTIVE

The objective of this review is to map the nature and extent of forgiveness facilitation intervention implemented and evaluated in palliative care contexts.

INTRODUCTION

Spiritual beliefs often include reconciliation and forgiveness, which are critical to patients and families in palliative care. Forgiveness facilitation can represent a valuable response as a multidisciplinary and non-pharmacological intervention to reduce suffering.

INCLUSION CRITERIA

Studies including palliative care patients aged 18 years or over and assisted by palliative care teams, including all healthcare professionals, chaplains, and volunteers, were included in this review.

METHODS

This scoping review is based on JBI methodology. The search was conducted in June 2017 and updated in December 2018 using international databases and gray literature in English, Spanish, German, Italian, and Portuguese.

RESULTS

A total of 23 articles were included in this review. The results suggest a growing interest in forgiveness facilitation in palliative care in different spiritual and religious traditions. Most studies are based on a psychological perspective. Several activities related to the intervention have been identified, but few details or characteristics are described. Social workers, nurses, doctors, and psychologists were most identified as healthcare staff involved in forgiveness facilitation. The outcomes related to the intervention are mental, physical, and relational well-being; quality of life, decision-making and communication; self-esteem and hope; depression, anger, and anxiety; and inner peace.

CONCLUSIONS

Forgiveness facilitation is critical in palliative care and is grounded in a multidisciplinary approach, but further evidence is needed to inform clinical implementation. These results open new perspectives for research and training on palliative healthcare staff.

Nurses and Patients' Perspectives on Spiritual Health Assessment

Nurses conduct physical and psychosocial assessments during admissions to healthcare facilities. Patients rely upon nurses to provide support and education during their journey, from periods of health decline to states of optimal wellness. Therefore, nurses are an ideal population to assess spiritual health. The value and necessity of spiritual assessment were explored on an inpatient unit providing medical and palliative care to patients. Two spiritual assessment tools, comprised each of five items, were evaluated by nursing staff and patients. Spiritual Assessment Tool 1 used language that was unaffiliated with religion, nor a belief in God, and Spiritual Assessment Tool 2 used language affiliated with faith and belief in God.

Holding onto Hurt: The Prevalence of Interpersonal Hurt and Need for Forgiveness-Focused Solutions for Hospice Family Caregivers

Background: Interpersonal hurt or offenses are common human experiences. Bereavement may be impacted for caregivers of a terminally ill loved one when these experiences occur. Objective: To determine the prevalence and impact of interpersonal hurt-based experiences for hospice caregivers and interest in forgiveness-based support. Design: Cross-sectional, mixed methods needs assessment. Settings/Subjects: Bereaved hospice caregivers (n = 162) and direct care hospice clinicians (n = 133) were surveyed through mail-in and online surveys. Measurements: Participants completed ad hoc surveys to assess prevalence and impact of interpersonal hurt experiences and interest in forgiveness-based support. Bereaved caregivers also completed the Core Bereavement Items (CBI). Results: 41.98% of the bereaved experienced an interpersonal hurt or offense during the care or passing of their loved one. Those with hurt experiences felt highly impacted (63.2%), "sometimes" or "often" revisited the experience (91.2%), felt that their bereavement was affected (61.5%), and experienced physical symptoms (46.3%). CBI scores positively correlated with the impact of the experience. Hurt caregivers had higher CBI scores compared with those who did not. Of those who had not forgiven the offender, 46.3% felt that they could benefit from forgiveness-based support services. Qualitative analysis revealed themes of Disagreements with Decisions, Lack of Support, Relational Interactions, and Impact on Bereavement. Clinician responses supported these results. Conclusions: Interpersonal hurt experiences can greatly impact the offended caregiver during caregiving and in bereavement. However, it should be noted that the decision to forgive is ultimately a personal choice and therefore forgiveness-based for forgiveness-specific interventions may not be appropriate for all individuals. Future research should assess the feasibility and usefulness of this type of support for caregivers and the bereaved.

Clinicians' accounts of communication with patients in end-of-life care contexts: A systematic review

OBJECTIVE

Communication between patients and end-of-life care providers requires sensitivity given the context and complexity involved. This systematic review uses a narrative approach to synthesise clinicians' understandings of communication in end-of-life care.

METHODS

A systematic, narrative synthesis approach was adopted given the heterogeneity across the 83 included studies. The review was registered prospectively on PROSPERO (ID: CRD42019125155). Medline was searched for all articles catalogued with the MeSH terms "palliative care," "terminal care" or "end-of-life care," and "communication". Articles were assessed for quality using a modified JQI-QARI tool.

RESULTS

The findings highlight the centrality and complexity of communication in end-of-life care. The challenges identified by clinicians in relation to such communication include the development of skills necessary, complexity of interpersonal interactions, and ways in which organisational factors impact upon communication. Clinicians are also aware of the need to develop strategies for interdisciplinary teams to improve communication.

CONCLUSION

Training needs for effective communication in end-of-life contexts are not currently being met.

PRACTICE IMPLICATIONS

Clinicians need more training to address the lack of skills to overcome interactional difficulties. Attention is also needed to address issues in the organisational contexts in which such communication occurs.

Forgiveness and Reconciliation Processes in Dying Patients With Cancer

This article studies forgiveness and reconciliation (F/R) in patients with cancer. It focuses on the end of life, when family conflicts resurface and unfinished business challenges patients and causes spiritual distress. Forgiveness and reconciliation may intensify patient–family relationships and facilitate peace of mind and peaceful death. Existing forgiveness models and interventions focus on coping in life, yet no study has examined F/R processes until death. Our mixed-method exploratory study hypothesized that F/R processes occur in phases, repeatedly, and are spurred by approaching death. Three interdisciplinary units at a major Swiss hospital observed 50 dying patients with cancer experiencing severe conflicts with relatives, themselves, and/or with fate/God. Participant observation was combined with interpretative phenomenological analysis and descriptive statistical analysis. A semi-structured observation protocol was developed based on a 5-phase model. The protocol included space for notes (emotions, interventions, effects on dying processes). It was assessed by 20 professionals for 1 year. Analysis was supported by international interdisciplinary experts. We found that conflicts were complex and involved relational, biographical, and spiritual layers. In 62% of patients, F/R processes occurred repeatedly. Many patients died after finding F/R (22 within 48 hours). Patients indicated that imminent death, a mediating third party, acceptance, and experiences of hope motivated them to seek F/R. Although deep relationships may support F/R processes, our limited data on near-death experience/spiritual experiences restrict interpretation. Forgiveness and reconciliation processes oscillate between 5 phases: denial, crisis, experience of hope, decision, and finding F/R. Understanding F/R processes, empathy, hope, and a neutral third party may support patients in seeking forgiveness.

How People Forgive: A Systematic Review of Nurse-Authored Qualitative Research

Purpose: The aim of this systematic review of qualitative forgiveness studies by nurse authors is to contribute to the body of holistic nursing knowledge by discovering answers to the following research questions: (a) where/how does a person get the power to forgive? and (b) what are the people who forgive like? Method: We conducted a systematic search of the English language, peer-reviewed literature for nurse-authored, primary qualitative research that answered our research questions. A total of 188 potential studies were found, and 11 studies met the inclusion criteria. Results: Study participants used interpersonal, intrapersonal, and transpersonal sources of power to forgive, including prayer, meditation, and support from family, friends, and nurses. The findings also revealed the cognitive, emotional, and spiritual traits of forgiving people, including being faith oriented, empathetic, and understanding the meaning of forgiveness as letting go of negative emotions. The findings confirm activities listed under “Forgiveness Facilitation” (2018) in Nursing Interventions Classification (NIC) and suggest additions. Conclusion: This literature review adds to nursing knowledge by synthesizing the findings of the review in a way that provides guidance to nurses to help facilitate forgiveness with patients who want that.

Spiritual Care Communication in Cancer Patients

OBJECTIVES

To provide a definition of spirituality, define the scope and nature of spiritual care communication, describe how to initiate communication about, and elicit, a spiritual history, and introduce the AMEN protocol to support patient/family hopes for a miracle.

DATA SOURCES

Literature review.

CONCLUSION

Spiritual communication is important throughout cancer care. Nurses can assess and integrate patient and family caregivers' spiritual needs in clinical care by practicing self-awareness and engaging in spiritual care communication strategies.

IMPLICATIONS FOR NURSING PRACTICE

Spirituality is recognized as an essential component of quality care. Spiritual conversations can increase patients' satisfaction with care and improve well-being.

Forgiveness facilitation in palliative care: a scoping review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this scoping review is to map the nature and extent of forgiveness facilitation interventions that have been implemented and evaluated in palliative care contexts. More specifically, the review questions are.

Moral competency: meta-competence of nursing care

Introduction

To follow the progress of technology and increasing domain of nurses’ duties, ethical challenges can be observed more than ever. Therefore, the growing and dynamic system of nursing requires nurses with professional and ethical competence who can provide optimal care. The aim of the present study was to define and explain dimensions of moral competency among the clinical nurses of Iran.

Methods

This qualitative content analysis study was carried out in the years 2014 and 2015 in Iran. Data were collected through in-depth semistructured interviews and field notes. The resulting data were analyzed by Graneheim and Lundman’s method of conventional content analysis. The participants were 12 clinical nurses who were selected using purposive convenient sampling and continued interviews until data saturation.

Results

Themes obtained in the present study were posited in three main categories of “moral character,” with subcategories of altruism, search for meaning, be pioneering, perfectionism, self-control, honesty, and forgiveness; “moral care” with subcategories of dignified care, safe care, fair care, and holistic care; and “moral decision-making” with subcategories of moral sensitivity, moral thinking, moral reasoning, and moral courage.

Conclusions

Findings of the present study suggest that nurses’ moral competency is an adorable character with a wide range that includes moral virtues and character, moral decision-making, and ultimately providing moral care; therefore, moral competency is a meta-competence in the field of nursing. Because there are many competencies in different fields.

At the Grave We Make Our Song: A Palliative Care Study in Rural Guatemala

Purpose: We sought to understand decision making, family involvement, and cultural factors that influence palliative care for Guatemalans. Design: A qualitative descriptive study was conducted in Guatemala to explore palliative care experiences among seven participants. Findings: The overarching theme was Relief from Suffering, reinforced by three support systems: the family, community rezadora, and priest. The family made decisions and provided physical care. The rezadora sang prayers and prepared the home altar. The priest provided traditional sacraments. Discussion: The role of the rezadora should be considered in providing palliative care to Guatemalans. Some Guatemalans are unfamiliar with or have difficulty understanding the role of the nurse in palliative and end-of-life care. Implications: We suggest training opportunities using international resources to enhance the role for Guatemalan nurses in end-of-life care. Palliative care nurses in the United States may benefit from incorporating the rezadora into strategies that extend these services to Guatemalans.

Exploring the spiritual needs of families with seriously ill children

Although we know that families of seriously ill children experience spiritual distress, especially at the end of the child's life, there is little information on the specific spiritual needs of families. In order to develop further training for nurses in paediatrics and help nurses develop skills for communicating about spirituality, this research examined the spiritual needs of families based on nurses' experiences with families of seriously ill children. Nurses' experiences revealed that families' anger with God, blame/regret, forgiveness, and ritual and cultural traditions are salient spiritual needs requiring effective nurse communication skills to support families of ill children.

Provider Difficulties With Spiritual and Forgiveness Communication at the End of Life

Background:

Due to an absence of communication training, provider responses to patient/family spiritual distress are highly variable. Assessing spiritual and forgiveness concerns are important to ensuring quality holistic care.

Methods:

Cross-sectional survey data were collected from providers attending 1 of 2 continuing education courses. The survey measured the frequency and initiation of communication about spirituality and forgiveness with patients/families, the perceived difficulty in communication across topics, and preparation and resources for these discussions.

Results:

Most participants (n = 124) were nurses followed by social workers with over half of providers having 10 years or more of clinical experience. Participants reported the highest level of difficulty in spiritual communication when talking with family after the death of a patient, followed by conducting a spiritual history with a patient. Facilitating forgiveness communication between parent and adult child, followed by facilitating forgiveness between partners was most difficult for all participants. Social workers reported much lower difficulty than nurses on all items of spiritual and forgiveness communication.

Conclusion:

The majority of participants indicated they were involved in spiritual and forgiveness communication. The most difficult communication included talking with family after death and facilitating forgiveness between patients and families. These findings support the importance of spiritual communication in clinical practice, and the need for clinician training in communicating about spirituality and forgiveness with patients and families.