Bereavement Support on the Frontline of COVID-19: Recommendations for Hospital Clinicians

Psychological Distress and the Needs of Family Members of Critically Ill Patients in Emergency Departments During the COVID-19 Pandemic: A Cross-Sectional Study

INTRODUCTION

The literature highlights the importance of the needs of family members of critical patients in emergency departments. Understanding these needs helps to alleviate psychological distress and contribute to the patients' recoveries. This study aimed to examine the psychological distress and needs of family members of critical patients in emergency departments.

METHODS

A cross-sectional design was used to collect data using the Depression, Anxiety, and Stress Scale-21, the Critical Care Family Needs Inventory for the Emergency Department, and the Needs Met Inventory questionnaire from a convenience sample of 170 family members of critical patients. Descriptive analysis and importance-performance analysis were applied to analyze the data.

RESULTS

The results showed that 52.4% of family members reported mild to extremely severe levels of depression, 60% reported mild to extremely severe levels of anxiety, and 53.5% had mild to extremely severe levels of stress. Anxiety showed a significant negative correlation with comfort needs (r = -0.17) and support needs being met (r = -0.16). The importance-performance analysis showed that the coordinates for support needs were in quadrant IV, signifying a higher level of importance perceived by family members but a lower level of the needs being met.

CONCLUSION

Providing the assessment and necessary support to alleviate psychological distress will help enhance the ability of the emergency department to meet families' needs.

Care of the Patient Nearing the End of Life in the Neurointensive Care Unit

BACKGROUND

Neurologically critically ill patients present with unique disease trajectories, prognostic uncertainties, and challenges to end-of-life (EOL) care. Acute brain injuries place these patients at risk for underrecognized symptoms and unmet EOL management needs, which can negatively affect their quality of care and lead to complicated grief in surviving loved ones. To care for patients nearing the EOL in the neurointensive care unit, health care clinicians must consider neuroanatomic localization, barriers to symptom assessment and management, unique aspects of the dying process, and EOL management needs.

AIM

We aim to define current best practices, barriers, and future directions for EOL care of the neurologically critically ill patient.

The effects of occupational disruption during COVID-19 lockdowns on health: a cross-sectional study

The disruption in daily activity performance during COVID-19 lockdowns is widely understood to have impacted health, but a better understanding of how restricted performance of specific activities are associated with health is needed. This cross-sectional study answers the following question: How were changes in the performance of 16 daily activities associated with health during COVID-19 lockdowns? A total of 116 participants completed an online survey rating their health before and during COVID-19 lockdowns and comparing their recollection of the performance of 16 activities before COVID-19 with their performance during lockdowns. Multiple stepwise linear regression analysis was used to estimate the relationship between self-reported changes in activities during lockdowns and concurrent (during-lockdown) health status, while controlling for pre-COVID-19 health status. Only changes in activities that were uniquely and significantly associated with lockdown health status were retained in the final model. Health before COVID-19 accounted for 3.7% (P = 0.039) of the variance in health during COVID-19 lockdowns. After controlling for health before COVID-19, five types of activity were significantly and uniquely predictive of health during lockdowns, together accounting for 48.3% of the variance. These activities and the variances they accounted for were rest and sleep (29.5%, P < 0.001), play and recreational activities (8%, P < 0.001), work (4.8%, P = 0.002), personal hygiene (3.2%, P = 0.01), and healthy eating (2.8%, P = 0.013). The study suggests that these five types of activity should be prioritized in policy or interventions when participation in activity is constrained by lockdowns or comparable factors.

Frontline nurses' experiences of managing visitor restrictions during the COVID-19 pandemic in a Danish university hospital - Lessons learned

BACKGROUND

Worldwide visitor restrictions forced nurses to separate patients from their relatives. However, the experience of implementing shifting restrictions from the frontline nurses' perspectives in a Danish context has yet to be assessed.

AIM

The aim of this descriptive qualitative study was to explore frontline nurses' experiences of managing shifting visitor restrictions in a Danish somatic university hospital during the COVID-19 pandemic.

METHODS

An online questionnaire, including open-ended questions, was developed. Data were analysed using descriptive statistics and content analysis.

FINDINGS

116 nurses from 29 departments participated; they were informed about restrictions primarily by their charge nurses and hospital intranet. Shifting visitor restrictions compelled the nurses to constantly adjust and negotiate their practices. When deciding to suggest deviating from the restrictions, they shared their decision-making with colleagues. Visitor restrictions left the hospital environment quieter, but they also created a lack of overview and predictability, an emotional burden, and a negative impact on the quality of care.

CONCLUSION

Restricting relatives' access challenged the nurses' professional values, and it seems to have affirmed their appreciation of relatives' role as important partners in contemporary hospital-based health care.

COVID-19 Ruptures And Disruptions on Grieving And Mourning Within an African Context: Lessons For Social Work Practice

Losing a significant other through death is a tragic experience worsened by the novel coronavirus disease 2019 (COVID-19). To curb this massive increase of deaths, the South African government introduced various rules to regulate the burial process. However, these COVID-19 regulations have caused major ruptures and disruptions on how bereaved families observe and practice cultural rites and customs following death within an African context. Consequently, many bereaved family members, particularly Black Africans, struggle with adhering to the regulations and funerals have been coined 'super spreaders' of the virus. The concerns raised in this article are twofold, namely, the impact of the Covid-19 regulations on how Black Africans grieve and mourn, as well as the involvement of social workers in formulating regulations that ought to be adhered to. This article explores the fissures and bricolages brought about by COVID-19, ultimately suggesting possible ways of dealing the losses ascribed to the pandemic.

Lived Experiences Among Critically Ill and Near-Death Survivors Relating to the COVID-19 Infection: A Phenomenological Study

INTRODUCTION

The COVID-19 pandemic has resulted in severe illnesses worldwide. Around 655.5 million cases were having been confirmed, including 6.6 million deaths. The extreme cases experienced near death in the intensive care unit (ICU). This study explored the survivors' experience of being near death while critically ill with the infection.

METHODOLOGY

A descriptive phenomenological study was employed. Data were collected through in-depth interviews with 14 participants from Northeastern Thailand. Content analysis was applied by using Creswell's strategy.

RESULTS

Four themes emerged: (a) anxiety and fear of dying alone, (b) environmental chaos, (c) using Thai Buddhist teaching in coping, and (d) returning from the brink of death. Moreover, the patients felt great gratitude and were grateful to the health care team.

DISCUSSION

Traumas experienced by patients in the ICU included physical and psychological distress, coping strategies, and an understanding of cultural awareness.

CONCLUSION

Psychological and culturally congruent care should be implemented for patients in the ICU.

Connecting Families to Bereavement Resources: A Hospital-Based, Bereavement Follow-Up Pilot During First-Wave COVID-19

Background: Hospitals often lack bereavement programs. Bereaved families often navigate grief support on their own. This problem was complicated by the early COVID-19 pandemic. Objective: Describe a cost neutral pilot to support next of kin (NOK) of deceased patients from our communicable disease response unit (CDRU) and palliative care unit (PCU). Design: Ad hoc pilot leveraging chaplains and a social worker (SW) to call NOK for grief support using a templated guide, referring interested NOK to bereavement support agencies. Setting/Subjects: NOK of patients who died in the CDRU and PCU at a metropolitan, quaternary care, hospital over five months. Results: One hundred eighty-six patients died. Eighty-one NOK were called, 51 calls were considered complete. Fourteen NOK accepted a referral for bereavement support. Conclusions: This cost neutral pilot successfully connected 81 NOK with either a pilot chaplain or SW for bereavement support. Fourteen NOK accepted referral for a community bereavement resource.

Description and Analysis of Research on Death and Dying during the COVID-19 Pandemic, Published in Nursing Journals Indexed in SCOPUS

AIM

To offer an overall picture of the research published regarding the different aspects of death and dying during the COVID-19 pandemic in journals covering the field of nursing in the Scopus database.

DESIGN

bibliometric analysis.

METHODS

The metadata obtained were exported from Scopus for subsequent analysis through Bibliometrix. Using the VOSviewer co-word analysis function, the conceptual and thematic structure of the publications was identified.

RESULTS

A total of 119 papers were retrieved, with the participation of 527 authors. The publications were found in 71 journals covering the nursing area. The main lines of research revolved around the keywords "palliative care" and "end-of-life care" in regard to the ethical, psychological, and organizational challenges faced by the health professionals who cared for these patients.

CONCLUSION

The results obtained offer a range of data and images that characterize the scientific production published on this topic, coming to the conclusion that, due to the multifaceted and multidisciplinary approach to the experience of death, care, and accompaniment in the dying process, bibliometric maps improve the comprehensive understanding of the semantic and conceptual structure of this field of research. This study was retrospectively registered with the OSF Registries on the 14 March 2024.

Experiences with and needs for aftercare following the death of a loved one in the ICU: a mixed-methods study among bereaved relatives

BACKGROUND

Bereaved relatives of intensive care unit (ICU) patients are at increased risk of psychological complaints. Aftercare might help them cope with processing the ICU admission and their loved one's death. There is little (qualitative) evidence on how bereaved relatives experience aftercare. Also, the COVID-19 pandemic likely impacted aftercare provision. We aim to examine how many relatives in Dutch ICUs received aftercare before and during the pandemic and to qualitatively describe their experiences and needs regarding aftercare.

METHODS

A mixed-methods study among relatives of patients who died in an ICU before or during the COVID-19 pandemic. Bereaved relatives in six ICUs completed a questionnaire (n = 90), including two items on aftercare. These were analyzed using descriptive statistics and Chi-squared tests. Subsequently, both relatives that received and relatives that did not receive aftercare were interviewed about their experiences and needs regarding aftercare. The interviews were thematically analyzed.

RESULTS

After the passing of a loved one, 44% of the relatives were asked by a healthcare professional from the hospital how they were doing, and 26% had had a follow-up conversation. Both happened more often during the first wave of the pandemic than during the second wave or before the pandemic. The most common reason for not having had a follow-up conversation was not knowing about this option (44%), followed by not feeling a need (26%). Regarding the latter, interviewed relatives explained that this would not revive their loved one or that they had already discussed everything they wanted. Relatives who wanted a follow-up conversation, wanted this because this would help them realize the severity of their loved one's illness, to exchange personal experiences, and/or to thank the ICU team. Those with a follow-up conversation said that they had reviewed the medical course of the admission and/or discussed their (mental) well-being.

CONCLUSIONS

ICU healthcare professionals may play a vital role in addressing aftercare needs by asking relatives how they are doing in the weeks following the death of their loved one and offering them a follow-up conversation with an ICU physician. We recommend to include aftercare for bereaved relatives in ICU guidelines.

Challenges of using body bags for COVID-19 deaths from the healthcare provider perspective - a qualitative study

BACKGROUND

During the COVID-19 pandemic, numerous issues regarding end-of-life care for COVID-19 patients have been discussed. Among these issues, challenges related to the use of body bags following the death of COVID-19 patients have been suggested. This study aimed to identify the challenges faced by healthcare professionals (HCPs) when using body bags after the death of patients infected with COVID-19 in medical settings.

METHODS

We conducted a qualitative descriptive study with semistructured in-depth interviews using inductive thematic analysis. From August to December 2021, we interviewed nurses and doctors who provided end-of-life care to COVID-19 patients focusing on their experiences with the use of body bags for the deceased.

RESULTS

Of the 25 interviewees who mentioned body bag use, 14 were nurses (56%) and 13 were women (52%). The mean interview length was 52.0 min (SD 9.6 min). Challenges associated with body bag use were classified into four themes with eight categories: preserving the dignity of the deceased, consideration for the bereaved saying a final goodbye to a loved one in a body bag, the physical and emotional impact on HCPs, and diverse opinions on body bag use.

CONCLUSION

Our findings include ethical concerns about the dignity of the deceased, empathy for the grief of bereaved families, and the emotional and physical distress experienced by HCPs struggling with the recommendation to use body bags based on limited evidence. The diverse perspectives of HCPs in this study highlight potential issues that developers should consider when formulating more appropriate and acceptable guidelines/guidance and policies.

Nurses' perceptions about bereavement care in critical care units: A qualitative study

AIM

To explore critical care nurses' perceptions of bereavement nursing care in critical care settings at a tertiary hospital in Singapore.

BACKGROUND

Grief and bereavement are stressful life experiences associated with significant health problems. Critical care nurses play important roles in supporting bereaved family members, and their self-competence affects the quality of the care they deliver. Exploring critical care nurses' perceptions of bereavement nursing care is thus essential.

METHODS

An exploratory descriptive qualitative study design was adopted. A total of 16 nurses were recruited. One-on-one interviews were conducted using a semi-structured interview guide and were audio-recorded. The data collected were analysed using thematic analysis. This study was reported according to the Consolidated Criteria for Reporting Qualitative Research checklist.

FINDINGS

Five themes surfaced in the study, namely, family responses, holistic care, psychological impact, self-competence and organisational dynamics.

CONCLUSION

This study highlighted the key roles of critical care nurses in providing bereavement care, how their self-competence impacts care delivery and the significant impacts of organisational policies on their capacity to provide care.

IMPLICATIONS FOR NURSING AND NURSING POLICY

Nursing administrators should provide enhanced organisational support to critical care nurses who provide bereavement nursing care, and implement training work plans to ensure nurses are adequately prepared to provide culturally appropriate care. Strategies should be introduced to reduce administrative burden, expand the role of critical care nurses in providing bereavement nursing care, and establish and enlist role models as drivers of bereavement nursing care.

Patient safety and hospital visiting at the end of life during COVID-19 restrictions in Aotearoa New Zealand: a qualitative study

BACKGROUND

Visiting restrictions were enacted in Aotearoa New Zealand to reduce transmission of COVID-19 and protect the healthcare system. This research aimed to investigate the experiences of families and clinicians of hospital visiting for people with palliative and end-of-life care needs during restrictions.

METHODS

Semistructured interviews were completed between March and October 2021 with family members and clinicians who had personally experienced enactment of visiting restrictions during pandemic restrictions. A critical realist ontology was used to approach data analysis, sorting and coding to generate themes.

RESULTS

Twenty-seven participants were interviewed, 13 being families who had experienced bereavement of a family member during the restrictions: seven nurses or physicians and seven being non-bereaved family members. Four themes were generated: patient safety-(re)defining the 'Visitor'; the primacy of SARS-CoV-2-patient safety and negotiating risk; dying alone: enduring harms; and agency, strategies and workarounds.

CONCLUSION

Visitor rights and visitor policy at the end of life require greater protection during a pandemic. Transparent, coherent, publicly available evidence-based guidelines that key stakeholders, including patients, families and ethicists, are included in producing, are urgently required. We want to avert a legacy of disenfranchised grief in future pandemics.

Exploring the Use of Virtual Funerals during the COVID-19 Pandemic: A Scoping Review

The COVID-19 pandemic and physical distancing limitations have had a profound impact on funeral practices and associated grieving processes. The purpose of the present scoping review is to summarize the existing literature on the emerging use of virtual funerals. Five medical databases, five social science databases, and five grey literature databases were searched, identifying 1,351 titles and abstracts, of which 62 met inclusion criteria. Four themes, each with various subthemes emerged: (a) Impact of virtual funerals on coping with death; (b) Impact of the COVID-19 pandemic on the funeral industry; (c) Benefits and disadvantages of virtual funerals; and (d) Future implications for health and social work practitioners. Virtual funerals are an evolving resource for individuals, families, and communities to mourn in response to the interruptions to traditional grieving practices due to the COVID-19 pandemic.

Nurses' bereavement experiences of a deceased colleague due to COVID-19: A phenomenological study

AIM

Healthcare workers have little time to mourn due to the intensification of the COVID-19 pandemic. Although grief is a normal part of life and death, the circumstances surrounding the death can affect the grieving process. So far, the nurses' experience in mourn for a deceased colleague in the COVID-19 pandemic has not been determined. Identifying these experiences can provide opportunities to formulate appropriate strategies to functionally adapt to death and promote mental health and well-being during this crisis. This study aimed to understand the nurses' experiences in mourning for a deceased colleague due to COVID-19.

DESIGN

This was an interpretive phenomenological study.

METHOD

Participants included 10 nurses with the bereavement experience following the death of a colleague due to COVID-19, who were selected through purposive sampling, and the data were collected through in-depth and semi-structured interviews and analysed using Diekelmann et al.'s (1989) approach.

RESULTS

The nurses' bereavement experiences were in the form of eight themes: disbelief and amazement, acceptance with grief, lasting sadness, unsung laments, bringing back memories, impulse to leave the service, a professional myth and holy death. For nurses, mourning for the death of a colleague due to COVID-19 is like a lasting sadness that begins with disbelief and amazement and changes to acceptance with sadness. From the fellow nurses' point of view, this type of death was perceived as a holy death, which along with countless unsung laments and memories brought to us the association of a professional legend, and that such a fate would be inevitable for us as well, it was a push to leave the service.

PUBLIC CONTRIBUTION

Crisis managers and policymakers need to add protocols and training programs for resilience skills and healthy mourning.

Trends in Palliative Care Research During the COVID-19 Pandemic

To demonstrate the trends and variety of research on palliative care during the COVID-19 pandemic. A systematic search of the Web of Science database. Since the outbroke of the COVID-19 pandemic, the adjustment of palliative care systems is warranted to maintain a high quality of care. The COVID-19 -related palliative care studies account for approximately 4% of all publications on palliative care. However, there is a dearth of research investigating the nature of these studies. A total of 293 studies were included. Of the included studies, those related to system improvement were the most common (181/293, 61.8%), followed by those related to patient care (79/293, 27.0%), bereavement support for patients or family members (19/293, 6.5%), and the mental health of frontline practitioners (14/293, 4.8%). From these studies, 82, 137, and 74 studies were published in 2020, 2021, and 2022 (until August 1), respectively. The research trends of palliative care demonstrate the flexibility and rapid response of the global palliative care system to the COVID-19 pandemic and show how the palliative care system is evolving. While most studies are interested in system improvement, patient care, and bereavement support, the mental health of frontline practitioners has received less attention. Our findings provide palliative care practitioners with current valuable information and highlight possible future trends.

Barriers to and facilitators of advance care planning implementation for medical staff after the COVID-19 pandemic: an overview of reviews

OBJECTIVE

The COVID-19 pandemic has impacted the capacity for advance care planning (ACP) among patients, families and healthcare teams. We sought to identify and review the barriers to and facilitators of ACP implementation for medical staff in different settings (eg, hospitals, outpatient palliative care, nursing and care homes) during the pandemic.

DESIGN

This study employed an overview of reviews design. We searched the MEDLINE, CENTRAL, Web of Science and Embase databases for studies published between 8 December 2019 and 30 July 2023. We used AMSTAR 2 to assess the risk of bias.

RESULTS

We included seven reviews. Common barriers to ACP implementation included visitation restrictions, limited resources and personnel and a lack of coordination among healthcare professionals. In care and nursing homes, barriers included a dearth of palliative care physicians and the psychological burden on facility staff. Using telemedicine for information sharing was a common facilitator across settings. In hospitals, facilitators included short-term training in palliative care and palliative care physicians joining the acute care team. In care and nursing homes, facilitators included ACP education and emotional support for staff.

CONCLUSIONS

Visitation restrictions and limited resources during the pandemic posed obstacles; however, the implementation of ACP was further hindered by insufficient staff education on ACP in hospitals and facilities, as well as a scarcity of information sharing at the community level. These pre-existing issues were magnified by the pandemic, drawing attention to their significance. Short-term staff training programmes and immediate information sharing could better enable ACP.

PROSPERO REGISTRATION NUMBER

CRD42022351362.

Communication to promote and support physical distancing for COVID-19 prevention and control

BACKGROUND

This review is an update of a rapid review undertaken in 2020 to identify relevant, feasible and effective communication approaches to promote acceptance, uptake and adherence to physical distancing measures for COVID-19 prevention and control. The rapid review was published when little was known about transmission, treatment or future vaccination, and when physical distancing measures (isolation, quarantine, contact tracing, crowd avoidance, work and school measures) were the cornerstone of public health responses globally. This updated review includes more recent evidence to extend what we know about effective pandemic public health communication. This includes considerations of changes needed over time to maintain responsiveness to pandemic transmission waves, the (in)equities and variable needs of groups within communities due to the pandemic, and highlights again the critical role of effective communication as integral to the public health response.

OBJECTIVES

To update the evidence on the question 'What are relevant, feasible and effective communication approaches to promote acceptance, uptake and adherence to physical distancing measures for COVID-19 prevention and control?', our primary focus was communication approaches to promote and support acceptance, uptake and adherence to physical distancing.

SECONDARY OBJECTIVE

to explore and identify key elements of effective communication for physical distancing measures for different (diverse) populations and groups.

SEARCH METHODS

We searched MEDLINE, Embase and Cochrane Library databases from inception, with searches for this update including the period 1 January 2020 to 18 August 2021. Systematic review and study repositories and grey literature sources were searched in August 2021 and guidelines identified for the eCOVID19 Recommendations Map were screened (November 2021).

SELECTION CRITERIA

Guidelines or reviews focusing on communication (information, education, reminders, facilitating decision-making, skills acquisition, supporting behaviour change, support, involvement in decision-making) related to physical distancing measures for prevention and/or control of COVID-19 or selected other diseases (sudden acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), influenza, Ebola virus disease (EVD) or tuberculosis (TB)) were included. New evidence was added to guidelines, reviews and primary studies included in the 2020 review.

DATA COLLECTION AND ANALYSIS

Methods were based on the original rapid review, using methods developed by McMaster University and informed by Cochrane rapid review guidance. Screening, data extraction, quality assessment and synthesis were conducted by one author and checked by a second author. Synthesis of results was conducted using modified framework analysis, with themes from the original review used as an initial framework.

MAIN RESULTS

This review update includes 68 studies, with 17 guidelines and 20 reviews added to the original 31 studies. Synthesis identified six major themes, which can be used to inform policy and decision-making related to planning and implementing communication about a public health emergency and measures to protect the community. Theme 1: Strengthening public trust and countering misinformation: essential foundations for effective public health communication Recognising the key role of public trust is essential. Working to build and maintain trust over time underpins the success of public health communications and, therefore, the effectiveness of public health prevention measures. Theme 2: Two-way communication: involving communities to improve the dissemination, accessibility and acceptability of information Two-way communication (engagement) with the public is needed over the course of a public health emergency: at first, recognition of a health threat (despite uncertainties), and regularly as public health measures are introduced or adjusted. Engagement needs to be embedded at all stages of the response and inform tailoring of communications and implementation of public health measures over time. Theme 3: Development of and preparation for public communication: target audience, equity and tailoring Communication and information must be tailored to reach all groups within populations, and explicitly consider existing inequities and the needs of disadvantaged groups, including those who are underserved, vulnerable, from diverse cultural or language groups, or who have lower educational attainment. Awareness that implementing public health measures may magnify existing or emerging inequities is also needed in response planning, enactment and adjustment over time. Theme 4: Public communication features: content, timing and duration, delivery Public communication needs to be based on clear, consistent, actionable and timely (up-to-date) information about preventive measures, including the benefits (whether for individual, social groupings or wider society), harms (likewise) and rationale for use, and include information about supports available to help follow recommended measures. Communication needs to occur through multiple channels and/or formats to build public trust and reach more of the community. Theme 5: Supporting behaviour change at individual and population levels Supporting implementation of public health measures with practical supports and services (e.g. essential supplies, financial support) is critical. Information about available supports must be widely disseminated and well understood. Supports and communication related to them require flexibility and tailoring to explicitly consider community needs, including those of vulnerable groups. Proactively monitoring and countering stigma related to preventive measures (e.g. quarantine) is also necessary to support adherence. Theme 6: Fostering and sustaining receptiveness and responsiveness to public health communication Efforts to foster and sustain public receptiveness and responsiveness to public health communication are needed throughout a public health emergency. Trust, acceptance and behaviours change over time, and communication needs to be adaptive and responsive to these changing needs. Ongoing community engagement efforts should inform communication and public health response measures.

AUTHORS' CONCLUSIONS

Implications for practice Evidence highlights the critical role of communication throughout a public health emergency. Like any intervention, communication can be done well or poorly, but the consequences of poor communication during a pandemic may mean the difference between life and death. The approaches to effective communication identified in this review can be used by policymakers and decision-makers, working closely with communication teams, to plan, implement and adjust public communications over the course of a public health emergency like the COVID-19 pandemic. Implications for research Despite massive growth in research during the COVID-19 period, gaps in the evidence persist and require high-quality, meaningful research. This includes investigating the experiences of people at heightened COVID-19 risk, and identifying barriers to implementing public communication and protective health measures particular to lower- and middle-income countries, and how to overcome these.

Professional Roles, Services, and Quality of Life for End-of-Life Doulas in the United States

CONTEXT

End-of-life doulas provide support to the chronically ill, dying, and their families. However, little is known about the roles and services of doulas practicing in the United States.

OBJECTIVES

The purpose of the current study is to gain understanding of the roles and experiences of death doulas in the United States.

METHODS

The current study used concurrent triangulation mixed methods design combining survey data with video and audio file submissions from end-of-life doulas. The survey included demographics information, a questionnaire about the roles, services, and training of doulas, and the Professional Quality of Life Scale.

RESULTS

There were 74 (77.08%) complete responses from doulas practicing in the United States. Doulas shared about the types of services offered and professional roles they filled in work with the dying and their families. Many doulas offered hybrid or virtual services in addition to in-person care. Many worked at least partially on a volunteer basis. Professional Quality of Life Scales indicated a high level of compassion satisfaction, a low level of burnout, and a low level of secondary trauma.

CONCLUSION

In the complex healthcare system of the United States, end-of-life doulas offer valuable interpersonal services like legacy and grief work as well as practical services like financial and logistical end-of-life planning.

Prolonged grief during and beyond the pandemic: factors associated with levels of grief in a four time-point longitudinal survey of people bereaved in the first year of the COVID-19 pandemic

Background

The COVID-19 pandemic has been a devastating and enduring mass-bereavement event, with uniquely difficult sets of circumstances experienced by people bereaved at this time. However, little is known about the long-term consequences of these experiences, including the prevalence of Prolonged Grief Disorder (PGD) and other conditions in pandemic-bereaved populations.

Methods

A longitudinal survey of people bereaved in the UK between 16 March 2020 and 2 January 2021, with data collected at baseline (n = 711), c. 8 (n = 383), 13 (n = 295), and 25 (n = 185) months post-bereavement. Using measures of Prolonged Grief Disorder (PGD) (Traumatic Grief Inventory), grief vulnerability (Adult Attitude to Grief Scale), and social support (Inventory of Social Support), this analysis examines how participant characteristics, characteristics of the deceased and pandemic-related circumstances (e.g., restricted visiting, social isolation, social support) are associated with grief outcomes, with a focus on symptoms of PGD.

Results

At baseline, 628 (88.6%) of participants were female, with a mean age of 49.5 (SD 12.9). 311 (43.8%) deaths were from confirmed/suspected COVID-19. Sample demographics were relatively stable across time points. 34.6% of participants met the cut-off for indicated PGD at c. 13 months bereaved and 28.6% at final follow-up. Social isolation and loneliness in early bereavement and lack of social support over time strongly contributed to higher levels of prolonged grief symptoms, while feeling well supported by healthcare professionals following the death was associated with reduced levels of prolonged grief symptoms. Characteristics of the deceased most strongly associated with lower levels of prolonged grief symptoms, were a more distant relationship (e.g., death of a grandparent), an expected death and death occurring in a care-home. Participant characteristics associated with higher levels of prolonged grief symptoms included low level of formal education and existence of medical conditions.

Conclusion

Results suggest higher than expected levels of PGD compared with pre-pandemic times, with important implications for bereavement policy, provision and practice now (e.g., strengthening of social and specialist support) and in preparedness for future pandemics and mass-bereavement events (e.g., guidance on infection control measures and rapid support responses).

Advanced care planning in the early phase of COVID-19: a rapid review of the practice and policy lessons learned

Background

The importance of advance care planning (ACP) has been highlighted by the advent of life-threatening COVID-19. Anecdotal evidence suggests changes in implementation of policies and procedures is needed to support uptake of ACPs. We investigated the barriers and enablers of ACP in the COVID-19 context and identify recommendations to facilitate ACP, to inform future policy and practice.

Methods

We adopted the WHO recommendation of using rapid reviews for the production of actionable evidence for this study. We searched PUBMED from January 2020 to April 2021. All study designs including commentaries were included that focused on ACPs during COVID-19. Preprints/unpublished papers and Non-English language articles were excluded. Titles and abstracts were screened, full-texts were reviewed, and discrepancies resolved by discussion until consensus.

Results

From amongst 343 papers screened, 123 underwent full-text review. In total, 74 papers were included, comprising commentaries (39) and primary research studies covering cohorts, reviews, case studies, and cross-sectional designs (35). The various study types and settings such as hospitals, outpatient services, aged care and community indicated widespread interest in accelerating ACP documentation to facilitate management decisions and care which is unwanted/not aligned with goals. Enablers of ACP included targeted public awareness, availability of telehealth, easy access to online tools and adopting person-centered approach, respectful of patient autonomy and values. The emerging barriers were uncertainty regarding clinical outcomes, cultural and communication difficulties, barriers associated with legal and ethical considerations, infection control restrictions, lack of time, and limited resources and support systems.

Conclusion

The pandemic has provided opportunities for rapid implementation of ACP in creative ways to circumvent social distancing restrictions and high demand for health services. This review suggests the pandemic has provided some impetus to drive adaptable ACP conversations at individual, local, and international levels, affording an opportunity for longer term improvements in ACP practice and patient care. The enablers of ACP and the accelerated adoption evident here will hopefully continue to be part of everyday practice, with or without the pandemic.

Evidence Guiding Withdrawal of Mechanical Ventilation at the End of Life: A Review

OBJECTIVE

Distress at the end of life in the intensive care unit (ICU) is common. We reviewed the evidence guiding symptom assessment, withdrawal of mechanical ventilation (WMV) process, support for the ICU team, and symptom management among adults, and specifically older adults, at end of life in the ICU.

SETTING AND DESIGN

Systematic search of published literature (January 1990-December 2021) pertaining to WMV at end of life among adults in the ICU setting using PubMed, Embase, and Web of Science. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed.

PARTICIPANTS

Adults (age 18 and over) undergoing WMV in the ICU.

MEASUREMENTS

Study quality was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

RESULTS

Out of 574 articles screened, 130 underwent full text review, and 74 were reviewed and assessed for quality. The highest quality studies pertained to use of validated symptom scales during WMV. Studies of the WMV process itself were generally lower quality. Support for the ICU team best occurs via structured communication and social supports. Dyspnea is the most distressing symptom, and while high quality evidence supports the use of opiates, there is limited evidence to guide implementation of their use for specific patients.

CONCLUSION

High quality studies support some practices in palliative WMV, while gaps in evidence remain for the WMV process, supporting the ICU team, and medical management of distress. Future studies should rigorously compare WMV processes and symptom management to reduce distress at end of life.

Experience of loss and grief among people from Germany who have lost their relatives during the pandemic: the impact of healthcare professionals' support

Background

Due to public restrictions during the early stages of the COVID-19 pandemic, many people were unable to visit and bid a proper farewell to their dying loved ones. This study aimed to address the loss-oriented aspects of grief and bereavement of relatives and relate these to the support they may have received from their dying relative's caring professionals.

Materials and methods

People from Germany who experienced bereavement during the COVID-19 pandemic were enrolled in a cross-sectional study between July 2021 and May 2022, using standardized questionnaires (i.e., ICG, Inventory of Complicated Grief; BGL, Burdened by Grief and Loss scale; WHO-5, WHO-Five Wellbeing Index; and 5NRS, perception of burden related to the pandemic).

Results

Most participants (n = 196) had the opportunity to visit their relatives before death (59%). When this was not possible, being burdened by grief and loss was significantly higher (Eta2 = 0.153), while this had no significant influence on complicated grief or psychological wellbeing. Furthermore, 34% of participants felt well-supported by the treatment/care team. Their own support was moderately correlated with BGL scores (r = -0.38) and marginally with ICG scores (r = -15). Regression analyses showed that complicated grief symptoms as the dependent variable were predicted by (low) psychological wellbeing, relational status, and the perception of COVID-19-related burden (R2 = 0.70). In contrast, BGL as the dependent variable can be best explained by the perception of emotional affections because of restricted visits shortly before their death, by the (short) duration of visits before death, and by the relational status (R2 = 0.53). Although both were interconnected (r = 0.44), their predictor pattern was different.

Conclusion

Being able to visit dying relatives was important for the mourning and bereavement processes. This emotional aspect was more relevant to the normal, non-pathological grief and loss processes than to complicated grief processes. Support from their dying relatives' treatment/care team was highly relevant to the mourning process, but the visiting relatives often lacked information about additional resources such as psychologists or pastoral care professionals or had limited access to them.

A bad time to die? Exploring bereaved families/wha-nau experiences of end-of-life care under COVID-19 restrictions: a qualitative interview study

Background

There have been international concerns raised that, during the COVID-19 pandemic, there was an absence of good palliative care resulting in poor end-of-life care experiences. To date, there have been few studies considering the pandemic's impact on people dying from non-COVID-19 causes and their families and friends. In particular, there has been very less empirical research in relation to end-of-life care for Indigenous, migrant and minoritised ethnic communities.

Objectives

To explore bereaved next-of-kin's views and experiences of end-of-life care under COVID-19 pandemic regulations.

Design

This qualitative study involved in-depth one-off interviews with 30 ethnically diverse next-of-kin who had a family member die in the first year of the pandemic in Aotearoa, New Zealand.

Methods

Interviews were conducted by ethnically matched interviewers/interviewees. A reflexive thematic analysis was used to explore and conceptualise their accounts.

Results

A key finding was that dying alone and contracting COVID-19 were seen as equally significant risks by bereaved families. Through this analysis, we identified five key themes: (1) compromised connection; (2) uncertain communication; (3) cultural safety; (4) supported grieving and (5) silver linings.

Conclusion

This article emphasises the importance of enabling safe and supported access for family/whanau to be with their family/wha-nau member at end-of-life. We identify a need for wider provision of bereavement support. We recommend that policy makers increase resourcing of palliative care services to ensure that patients and their families receive high-quality end-of-life care, both during and post this pandemic. Policy makers could also promote a culturally-diverse end-of-life care work force and the embedding of culturally-safety practices across a range of institutions where people die.

Children's Experiences of Death Anxiety and Responses to the Covid-19 Pandemic

The aim of this study was to explore children's experience and responses to the Covid-19 pandemic through their illustrations and short narrations. During October 2020 and January 2021 data was collected from thirteen children aged 9-10 years old in a primary school in the North-West of England. Children were asked to draw their thoughts and feelings about the pandemic and to write a short narration to accompany the drawing. Thematic analysis of data revealed that during the pandemic children at this age have an understanding of death, experience death anxiety and are able to use creative expression to facilitate meaning of the impact of lockdown on their lives such as feeling isolated, lonely, sad and bored. Creative expression also facilitated adaptive coping mechanisms derived from being able to spend more time with family. The data on primary school children is part of a larger study which involved surveys and interviews with children aged 12-16 years in secondary schools.

Strategies for Virtual Bereavement Care

ABSTRACT

The contagiousness of some illnesses (e.g., COVID-19) limits the ways in which families can interact with their dying loved ones who have been admitted to the hospital, especially in the intensive care unit. As a result, nurses have developed culturally relevant strategies for virtual bereavement care for patients and families predeath, perideath, and postdeath. Specific ways nurses can support, communicate, and facilitate meaningful rituals when patients die in isolation are provided in this article.

Teaching (remotely) to communicate (remotely) with relatives of patients during lockdown due to the COVID-19 pandemic

Aim

In 2020, due to the pandemic, the lack of specific knowledge on breaking bad news over the phone became apparent. This study aims at assessing the differences, or lack thereof, in satisfaction reported by participants in the different formats of a course in telephone communication for breaking bad news to families of patients, developed based on the previous experience of a team dedicated to this task during the peak of the pandemic.

Methods

Four courses were delivered, two in a fully streamed format and two in a blended format, part pre-recorded, part streamed. There were 41 attendants, mostly doctors, but also nurses, social workers, occupational therapists, and administrative staff who deal with families. Subsequently, a survey was conducted to assess the degree of satisfaction of the participants.

Results

Both formats scored very positively, with small advantages for the fully streamed format, mainly due to the difference in interaction activities.

Conclusions

The main conclusion is the need for these courses, which are demanded by the professionals themselves, without forgetting the benefit obtained from interprofessional education that enriches interaction and learning.

Innovation

The inclusion of administrative staff allows for a global vision of care for family members, which improves it.

Male nurses’ mental health and provision of emotional support during COVID-19: a thematic analysis

Background:

COVID-19 has created mental health challenges for nurses. However, it is unknown if there is a gendered influence on nurses’ experiences during the pandemic.

Aim:

The aim of this study was to explore the experiences of male nurses during COVID-19, including their mental health and experiences of providing emotional support.

Methods:

We conducted semi-structured interviews using Zoom with nine male nurses and analysed the interviews using thematic analysis.

Findings:

Male nurses experienced negative mental health outcomes from the pandemic, but participants attributed these outcomes to the context. Male nurses provided emotional support for patients, students, families and other staff and did not describe emotional support as a difficult part of their work. Participants identified their role as a ‘breadwinner’ of being part of their concern during COVID-19. Participants used a variety of approaches to manage the stressors from the pandemic and cautioned against alcohol as a coping strategy.

Discussion and Conclusions:

Participants provided emotional support routinely as part of their work and went to great lengths to do so. This finding differs from most published literature that suggests male nurses struggle with emotional and interpersonal aspects of nursing. Male nurses require emotional support and employers can note that need for support may present differently by gender.

"Untold Distress" - How did the COVID-19 pandemic affect those who had previously experienced an epilepsy-related bereavement?

PURPOSE

This study explores the impact of the COVID-19 pandemic and lockdown on people with lived experience of sudden bereavement as a consequence of an epilepsy-related death.

METHOD

We developed an online survey with fixed choice and open-ended response formats to collect data on grief symptoms and well-being during the pandemic. A total of 275 people bereaved by epilepsy-related deaths between 1980-2020 participated in this study: with 79 participants providing free-text responses for inductive thematic analysis.

RESULTS

In total, 84% of participants reported a bereavement following a sudden death of a person aged under 40, with 22% aged 19 and under. The majority (77% of participants) reported they had been thinking more about the person who died compared to before the COVID-19 outbreak and 54% had experienced more distressing flashbacks to the time of death. Additionally, 61% reported more difficulties falling asleep and staying asleep and 88% of participants reported that the outbreak and response measures had negatively impacted upon their mental health. Medication was being taken for a diagnosed mental health condition by 33% of participants at the time of the study. We categorized these negative experiences during COVID in to four main-themes - 'Family', 'Lifestyle', 'Personal Well-being' and 'Health Services and Shielding Populations'. The 'Personal Well-being' theme was inextricably linked to grief symptoms including 'reflection on the death', 're-exposure to feeling', 'grief', 'salience of sudden deaths in the media' and 'inability to commemorate anniversaries and rituals'. These findings were consistent for bereaved people irrespective of the recency of the death.

CONCLUSION

This study highlights the impact of the disruption caused by the pandemic on the grief-management of those bereaved by epilepsy-related death. Grief is not static and its management is connected to the psychosocial and formal support structures that were disrupted during the pandemic. The removal of these supports had an adverse effect upon the mental health and well-being of many bereaved. There is an urgent need for a system-wide transformation of epilepsy and mental health services to be inclusive of the needs and experiences of people impacted by sudden deaths in epilepsy and the contribution of the specialist service developed by families and clinicians to meet this gap.

Providing End-of-Life Care for Patients Dying of COVID-19 and Their Families in Isolated Death During the Pandemic in Japan: The Providing End-of-life Care for COVID-19 Project

BACKGROUND

Death resulting from COVID-19 in a hospital during the pandemic has meant death in isolation. Although many health care providers (HCPs) have struggled with end-of-life (EOL) care for these patients, the various strategies across hospitals are not well known.

RESEARCH QUESTION

What EOL care did HCPs give patients dying of COVID-19 and their families in hospitals during the COVID-19 pandemic? What were the key themes in care?

STUDY DESIGN AND METHODS

This qualitative study used individual, semistructured, internet, and face-to-face interviews. We recruited HCPs who provided EOL care to patients with COVID-19 dying in hospitals and their families. Purposive sampling was used through the academic networks at the School of Public Health, Kyoto University. Anonymized verbatim transcripts were analyzed thematically.

RESULTS

Fifteen doctors and 18 nurses from 23 hospitals in 13 regions across Japan participated; 16 participants (48%) were women, with an age range of 20 to 59 years (most were 30-39 years of age). Participants described 51 strategies, including providing physical and psychological-spiritual care, making connections, providing death care, and arranging care environments and bereavement care for patients and their families. Four themes emerged as prominent efforts in COVID-19 EOL care: maintaining relationships with isolated patients, connecting patients and families, sharing decision-making in isolation, and creating humanistic episodes.

INTERPRETATION

Proper application and awareness of the four themes may help HCPs to implement better EOL care. To compensate for limited memories resulting from isolation and rapid progression of the disease, communicating and creating humanistic episodes are emphasized. ICU diaries and the HCPs' arrangements based on cultural funerary procedures could be provided as grief care for the family and to build trust. EOL education and building partnerships among palliative care staff and nonmedical personnel on a regular basis may enhance the capacity to deliver the necessary support for EOL care.

Measuring moral distress in Swedish intensive care: Psychometric and descriptive results

OBJECTIVES

To investigate the construct validity and psychometric properties of the Swedish version of the Moral Distress Scale-Revised and to describe moral distress in an intensive care context.

RESEARCH METHODOLOGY/DESIGN

The Italian Moral Distress Scale-Revised was translated and semantically adjusted to the Swedish intensive care context. A web survey with 14 moral distress items, as well as three additional and eight background questions was answered by critical care nurses (N = 71) working in intensive care units during the second year of the coronavirus disease pandemic. Inferential and descriptive statistics were used to investigate the Italian four-factor model and to examine critical care nurses' moral distress.

RESULTS

The result shows a factor model of four components differing from the previous model. Critical care nurses demonstrated significant differences in moral distress regarding priorities compared to before the pandemic, type of household; experience as critical care nurses and whether they had supervised students during the pandemic.

CONCLUSION

The component structure might have originated from the specific situation critical care nurses perceived during the pandemic. The health care organisations' role in preventing and healing the effects of moral distress is important for managers to understand.

IMPLICATIONS FOR CLINICAL PRACTICE

Moral distress is common in intensive care and it is necessary to use valid instrument when measuring it. A psychometrical investigation of the Swedish version of the Moral Distress Scale-Revised, adapted for intensive care shows need for further semantic and cultural adaptation. Perceived priorities during the pandemic, household type, supervising during the pandemic and working experience were related to critical care nurses' experience of moral distress and managers need to be aware of conditions that may trigger such a response.

Moral Distress, Health and Intention to Leave: Critical Care Nurses' Perceptions During COVID-19 Pandemic

Introduction

Moral distress increases the risk that critical care nurses will lose the ability to provide quality nursing care.

Aims

To describe person-related conditions and perceptions of moral distress, health and intention to leave among critical care nurses in intensive care units, and to examine the relationship between person-related conditions, moral distress, health and intention to leave.

Method

Cross-sectional, with 220 critical care nurses in 15 Swedish ICUs, and data gathered via a self-reported questionnaire.

Results

Highest moral distress scores were reported in futile care and poor teamwork and 21% reported entertaining an intention to leave. Self-reported health was lower than before the COVID-19 pandemic and 4.1% reported pronounced exhaustion disorder. Self-reported health, reduced capacity to tolerate demands under time pressure, emotional instability or irritability, physical weakness, or being more easily fatigued and with decreased well-being were factors that had a relationship with futile care. Sleeping problems and intention to leave had a relationship with poor teamwork.

Conclusions

Different strategies are needed to reduce moral distress and the leadership is crucial for managing crises such as the COVID-19 pandemic.

Factors Associated With Higher Levels of Grief and Support Needs Among People Bereaved During the Pandemic: Results from a National Online Survey

We identified factors associated with higher levels of grief and support needs among 711 people bereaved during the COVID-19 pandemic in the UK (deaths 16 March 2020-2 January 2021). An online survey assessed grief using the Adult Attitude to Grief (AAG) scale, which calculates an overall index of vulnerability (IOV) (range 0-36), and practical and emotional support needs in 13 domains. Participants' mean age was 49.5 (SD 12.9); 628 (88.6%) female. Mean age of deceased 72.2 (SD 16.1). 311 (43.8%) deaths were from confirmed/suspected COVID-19. High overall levels of grief and support needs were observed; 28.2% exhibited severe vulnerability (index of vulnerability ≥24). Grief and support needs were higher for close relationships with the deceased (vs. more distant) and reported social isolation and loneliness (p < 0.001), and lower when age of deceased was above 40-50. Other associated factors were place of death and health professional support post-death (p < 0.05).

Narratives of loss: the impact of Covid-19 lockdown on experiences of loss, grief, and bereavement

Introduction Restrictions imposed to eliminate the spread of the coronavirus disease 2019 (COVID-19) virus had significant implications on peoples' experiences of caring for family/whānau at the end of life, and on their own bereavement process. Aim This qualitative research explored the impact of COVID-19 lockdown restrictions on experiences of loss, grief and bereavement in Aotearoa New Zealand. Methods This qualitative narrative research used semi-structured interviews with 10 participants who experienced the loss of a loved one during Levels 3 or 4 lockdown in Aotearoa New Zealand (23 March-13 May 2020). Interviews were coded using NVivo software and inductive thematic analysis was used to evaluate the data. Results Results were grouped into three themes: death experience; mourning in isolation; and availability of support. These themes provide insight into the challenges and difficulties participants faced when they experienced the death of a loved one during a COVID-19 lockdown, and the impact of these restrictions on their experiences of grief and bereavement. Discussion The findings from this research suggest there is an increased risk of prolonged grief among those bereaved during lockdown. Primary care professionals need to be aware of this increased risk in order to identify need and provide access to bereavement support.

Original Research: COVID-19 Vaccine Hesitancy Among Southern California Nurses

PURPOSE

The purpose of this study was to elucidate characteristics of vaccine-hesitant nurses at two large Southern California medical centers where rates of COVID-19 vaccination were lower than expected.

METHODS

This study is a secondary analysis of nurse participants in a cross-sectional study conducted at the two medical centers. Participants completed an online survey regarding their demographics; work setting and role characteristics; influenza vaccination history; COVID-19 knowledge and beliefs; and personal history of COVID-19 exposure, diagnosis, and disease impact (infection or death) on those closest to them.

RESULTS

Of 869 nurse participants, most (78.6%) were vaccinated and 21.4% were unvaccinated; more than half of the unvaccinated participants reported being unwilling to be vaccinated ("vaccine hesitant"). The χ 2 comparisons revealed no significant differences between vaccinated and vaccine-hesitant nurses in terms of education, contact with COVID-19 patients, work environment, or having friends and family impacted by COVID-19. Binary logistic regression showed that nurses who had no history of recent influenza vaccination were 10 times more likely to be vaccine hesitant, those who had inaccurate knowledge about COVID-19 vaccines were seven times more likely to be vaccine hesitant, and younger nurses and those with a prior COVID-19 diagnosis were approximately three times more likely to be vaccine hesitant. Furthermore, 17.3% of all participants were unwilling to recommend COVID-19 vaccination to others.

CONCLUSION

The findings offer a nuanced understanding of vaccine hesitancy among nurses and will be useful to the planning and development of policies, campaigns, and interventions aimed at increasing vaccination rates among nurses. Changing attitudes is essential, and particular attention must be paid to nurses who are unwilling to recommend vaccination to others. Effective interventions are needed.

Opinions and experiences of healthcare professionals regarding structured virtual patient visits in ICUs: A qualitative study

OBJECTIVES

This study aimed to reveal the experiences of healthcare professionals regarding a structured Virtual Patient Visit (sVPV) program implemented in an ICU during the coronavirus disease 2019 (COVID-19) pandemic and to share the process of establishing the program.

DESIGN

This qualitative, exploratory study was conducted using a semi-structured, in-depth interview method.

SETTING

The study was conducted in a university hospital ICU in Turkey (where a sVPV program was implemented) and comprised one physician, eight nurses, and one clerk who volunteered to participate in the study. The data were evaluated with content analysis, and themes and sub-themes were determined.

FINDINGS

Five themes and 13 subthemes were obtained: (1) an essential program during the pandemic, (2) contributing to patient's recovery, (3) family-centered care, (4) innovativeness, and (5) sustainability.

CONCLUSION

The results show that the sVPV program is highly innovative and effective and contributed to positive patient outcomes and family-centered care practices during the COVID-19 pandemic. In addition, it was revealed that in order to conduct sVPVs effectively, organizational planning, such as legal processes, and the employment of experienced and competent healthcare professionals, should be well managed.

CLINICAL RELEVANCE

A well-designed sVPV program specific to the setting alleviates anxiety among patients and family members, increases patient motivation and healing, and decreases the workloads of healthcare professionals. It is recommended that the sVPV program, which can be easily used during not only COVID-19 pandemics but also during other crises, be adopted in all ICUs and carried out by a dedicated nurse or healthcare provider.

Institutional Constraints as an Obstacle for Prioritizing Nursing Interventions During the COVID-19 Pandemic—Critical Care Nurses’ Experiences

Introduction

The demands of the pandemic such as staff shortages and limited resources combined with new guidelines regarding infection control may have required the prioritizing of nursing interventions.

Objectives

The aim of this study was to describe critical care nurses’ experiences of prioritizing nursing interventions for patients with COVID-19 in intensive care units (ICUs) during the pandemic.

Method

A qualitative descriptive study was gathered from open-ended questions included in a cross-sectional online questionnaire. Characteristics were presented using descriptive statistics, and open-ended questions were analyzed using qualitative content analysis with an inductive approach. The study was conducted in Sweden and focused on critical care nurses working in ICUs during spring 2021 and the second year of the COVID-19 pandemic.

Results

During the COVID-19 pandemic, 87% of the critical care nurses had provided orientations for new co-workers, and 52% had supervised intensive care nursing students. In all, 70 answered the question of whether they had prioritized nursing care differently during the pandemic; 86% reported that they had and 14% had not. The qualitative analysis resulted in one theme, Institutional constraints as an obstacle for nursing interventions, with three categories: Prioritizing lifesaving interventions, Performing nursing interventions less frequently, and Not able to provide the nursing care I wish to provide.

Conclusion

Institutional constraints as an obstacle for nursing interventions is the overall theme. It illustrates how critical care nurses have been forced to prioritize, thereby not being able to provide the nursing interventions they wanted to do provide, and it describes their feelings in this situation. The nurses need recovery and possibilities for reflection. The organization must also recover and not only return to how it was before the pandemic but also to learn from recent events and take actions to reduce the long-term effects on staffing.

Critical care nurses' perception of moral distress in intensive care during the COVID-19 pandemic - A pilot study

OBJECTIVES

To describe critical care nurses' perception of moral distress during the second year of the COVID-19 pandemic.

DESIGN/METHODS

A cross-sectional study involving a questionnaire was conducted. Participants responded to the Italian version of the Moral Distress Scale-Revised, which consists of 14 items divided in dimensions Futile care (three items), Ethical misconduct (five items), Deceptive communication (three items) and Poor teamwork (three items). For each item, participants were also invited to write about their experiences and participants' intention to leave a position now was measured by a dichotomous question. The data were analysed with descriptive statistics and qualitative content analysis. The study followed the checklist (CHERRIES) for reporting results of internet surveys.

SETTING

Critical care nurses (n = 71) working in Swedish adult intensive care units.

RESULTS

Critical care nurses experienced the intensity of moral distress as the highest when no one decided to withdraw ventilator support to a hopelessly ill person (Futile care), and when they had to assist another physician or nurse who provided incompetent care (Poor teamwork). Thirty-nine percent of critical care nurses were considering leaving their current position because of moral distress.

CONCLUSIONS

During the COVID-19 pandemic, critical care nurses, due to their education and experience of intensive care nursing, assume tremendous responsibility for critically ill patients. Throughout, communication within the intensive care team seems to have a bearing on the degree of moral distress. Improvements in communication and teamwork are needed to reduce moral distress among critical care nurses.

Fear of being infected with COVID-19 virus among the medical social workers and its relationship to their future orientation

COVID-19 has been studied extensively for its direct effects on healthcare workers. Despite this, very little is known about the effect of COVID-19 fear on future orientation. Studying medical social workers' fear of being infected with COVID-19 and their future orientation was the primary method used to examine this relationship. 204 Turkish medical social workers on the pandemic's front lines were included in the total sample. Social workers were found to be extremely concerned about contracting COVID-19. Although only gender is a significant predictor of the fear of contracting COVID-19 infection, the study also found that female social workers have a higher fear of infection than males. Also, no correlation exists between social workers' vaccination status and their fear of contracting COVID-19. There was a weak negative correlation between social workers' fear of contracting COVID-19 and their future orientation, but in general, social workers had a positive future orientation. Medical social workers and front-line health care providers can use these findings to develop effective and culturally appropriate intervention programs to reduce COVID-19 concerns and foster a forward-looking outlook.

Mitigating Moral Distress in Leaders of Healthcare Organizations: A Scoping Review

GOAL

Moral distress literature is firmly rooted in the nursing and clinician experience, with a paucity of literature that considers the extent to which moral distress affects clinical and administrative healthcare leaders. Moreover, the little evidence that has been collected on this phenomenon has not been systematically mapped to identify key areas for both theoretical and practical elaboration. We conducted a scoping review to frame our understanding of this largely unexplored dynamic of moral distress and better situate our existing knowledge of moral distress and leadership.

METHODS

Using moral distress theory as our conceptual framework, we evaluated recent literature on moral distress and leadership to understand how prior studies have conceptualized the effects of moral distress. Our search yielded 1,640 total abstracts. Further screening with the PRISMA process resulted in 72 included articles.

PRINCIPAL FINDINGS

Our scoping review found that leaders-not just their employees- personally experience moral distress. In addition, we identified an important role for leaders and organizations in addressing the theoretical conceptualization and practical effects of moral distress.

PRACTICAL APPLICATIONS

Although moral distress is unlikely to ever be eliminated, the literature in this review points to a singular need for organizational responses that are intended to intervene at the level of the organization itself, not just at the individual level. Best practices require creating stronger organizational cultures that are designed to mitigate moral distress. This can be achieved through transparency and alignment of personal, professional, and organizational values.

'It's not just all about the fancy words and the adults': Recommendations for practice from a qualitative interview study with children and young people with a parent with a life-limiting illness

BACKGROUND

Healthcare professionals report challenges in supporting dying patients who have dependent children. These parents are often uncertain how to meet the needs of their children and require appropriate support from professionals. There is limited evidence based guidance for professionals around this issue, which is informed by the views and experiences of children themselves.

AIM

To develop an understanding of the perspective of children on living with parental life-limiting illness and inform recommendations for healthcare professionals.

DESIGN

Qualitative semi-structured interviews were conducted, with thematic analysis of the data.

SETTING/PARTICIPANTS

A diverse sample of 32 children aged 6-17, whose parent was living with life-limiting illness, were recruited from across the United Kingdom.

RESULTS

Despite the challenges of living with a parent with a life-limiting illness, the children display agency in their response. The children: feel a responsibility to look after their family; negotiate a relationship with healthcare; employ strategies to maintain some normality; and ensure that the inevitable sadness does not become overwhelming.

CONCLUSIONS

Five recommendations for healthcare professionals were developed from the findings. Clinicians should encourage dying parents to: (1) acknowledge the agency of children; (2) recognise children's caregiving roles; (3) engender children's trust in healthcare; (4) maintain some normality; and (5) discuss emotions with their children. Implementing these recommendations will assist parents with a life-limiting illness to provide evidence-based support to their dependent children.

Bereavement outcomes in family members of those who died in acute care hospitals before and during the first wave of COVID-19: A cohort study

BACKGROUND

The COVID-19 pandemic has caused millions of deaths worldwide, leading to symptoms of grief among the bereaved. Neither the burden of severe grief nor its predictors are fully known within the context of the pandemic.

AIM

To determine the prevalence and predictors of severe grief in family members who were bereaved early in the COVID-19 pandemic.

DESIGN

Prospective, matched cohort study.

SETTING/PARTICIPANTS

Family members of people who died in an acute hospital in Ottawa, Canada between November 1, 2019 and August 31, 2020. We matched relatives of patients who died of COVID (COVID +ve) with those who died of non-COVID illness either during wave 1 of the pandemic (COVID -ve) or immediately prior to its onset (pre-COVID). We abstracted decedents' medical records, contacted family members >6 months post loss, and assessed grief symptoms using the Inventory of Complicated Grief-revised.

RESULTS

We abstracted data for 425 decedents (85 COVID +ve, 170 COVID -ve, and 170 pre-COVID), and 110 of 165 contacted family members (67%) consented to participate. Pre-COVID family members were physically present more in the last 48 h of life; the COVID +ve cohort were more present virtually. Overall, 35 family members (28.9%) had severe grief symptoms, and the prevalence was similar among the cohorts (p = 0.91). Grief severity was not correlated with demographic factors, physical presence in the final 48 h of life, intubation, or relationship with the deceased.

CONCLUSION

Severe grief is common among family members bereaved during the COVID-19 pandemic, regardless of the cause or circumstances of death, and even if their loss took place before the onset of the pandemic. This suggests that aspects of the pandemic itself contribute to severe grief, and factors that normally mitigate grief may not be as effective.

THE RELATIONS BETWEEN FEAR OF COVID-19, ANXIETY OF DEATH, AND MEANING OF LIFE AMONG NURSING STUDENTS

Abstract Aim of the study was to determine the effects of socio-demographic factors on fear of COVID-19, death anxiety, and meaning of life among nursing students, and to explain the relations between fear of COVID-19, death anxiety, and meaning of life. The study was conducted with 262 students on 7-27 October 2020 in a descriptive-correlational and cross-sectional design. According to the correlation analysis, a moderate and positive relationship was detected between Fear of COVID-19 Scale (CFS) and Turkish Death Anxiety Scale (TDAS) total score and subscale scores. The mean age of the students who participated in the study was found to be 20.63±2.31, 64.1% were female. It was found that 29% of the students had sleep problems in this period, and 7.6% were diagnosed with COVID-19, and 85.9% of themhad their close friends and relatives diagnosed with COVID-19. The majority of the students (n=16) who were diagnosed with COVID-19 passed this process under quarantine at home without treatment, 59.2% of them stated that someone in their close circle had a positive COVID-19 test, and 31.7% lost a relative due to COVID-19. The model that was created in the multiple linear regression analysis which was made to determine the effects of TDAS and Meaning of Life Questionnaire (MLQ) on CFS was found to be statistically significant (F:54.91, p

Strategies Addressing the Challenges of the COVID-19 Pandemic in Long-Term, Palliative and Hospice Care: A Qualitative Study on the Perspectives of Patients’ Family Members

Patients in long-term, palliative, and hospice care are at increased risk of a severe course of COVID-19. For purposes of infection control, different strategies have been implemented by the respective health care facilities, also comprising visitation and other forms of contact restrictions. The aim of the present study was to examine how these strategies are perceived by family members of patients in these settings. An exploratory, qualitative approach was used to examine perceptions of policies and strategies using partially standardized guided interviews analyzed by means of a thematic approach. Interviews were conducted with 10 family members of long-term, palliative, and hospice care patients. Interviewees were between 30 and 75 years old. Because of the pandemic-related measures, respondents felt that their basic rights were restricted. Results indicate that perceptions of strategies and interventions in long-term, palliative, and hospice care facilities are particularly influenced by the opportunity to visit and the number of visitors allowed. Strict bans on visits, particularly during end-of-life care, are associated with a strong emotional burden for patients and family members alike. Aside from sufficient opportunities for visits, virtual communication technologies need to be utilized to facilitate communication between patients, families, and caregivers.

COVID-19: Challenges and solutions for the provision of care to seriously ill and dying people and their relatives during SARS-CoV-2 pandemic - perspectives of pandemic response team members: A qualitative study on the basis of expert interviews (part of PallPan)

BACKGROUND

During the SARS-CoV-2 pandemic's initial waves, bans on visiting and isolation measures placed limits on providing services for seriously ill and dying people and their relatives. Pandemic response teams at governmental level (macro), at federal state and municipal level (meso) and in healthcare facilities (micro) played their role in pandemic management procedures.

AIM

To explore pandemic-related challenges and solutions of pandemic response teams regarding the provision of care to seriously ill and dying people and their relatives. Findings were to be integrated into a national strategy (PallPan).

DESIGN

Semi-structured expert interviews (10/2020-2/2021) analysed via structured content analysis.

SETTINGPARTICIPANTS

We interviewed 41 members, who discussed the work of 43 German pandemic response teams (micro n = 23; meso n = 20; no members were available at macro level) from 14 German federal states.

RESULTS

Twenty-nine of 43 teams took account of the needs of seriously ill and dying. Their main challenges resulted from pandemic-related legal requirements in hospitals and long-term care facilities. The implementation of such was in the remits of the meso level. Dysfunctional or non-existent communication between the levels was reported to be challenging. To foster patient-related solutions the micro level pandemic response teams supported individual decisions to enable patient-relative contact for example, visiting and saying goodbye outside, meeting via digital solutions.

CONCLUSIONS

Pandemic response teams evidently struggled to find appropriate solutions to ease pandemic-related impact on the care of seriously ill and dying patients and their relatives. We recommend bringing palliative care expertise on board.

Comparative end-of-life communication and support in hospitalised decedents before and during the COVID-19 pandemic: a retrospective regional cohort study in Ottawa, Canada

OBJECTIVE

To compare end-of-life in-person family presence, patient-family communication and healthcare team-family communication encounters in hospitalised decedents before and during the COVID-19 pandemic.

DESIGN

In a regional multicentre retrospective cohort study, electronic health record data were abstracted for a prepandemic group (pre-COVID) and two intrapandemic (March-August 2020, wave 1) groups, one COVID-19 free (COVID-ve) and one with COVID-19 infection (COVID+ve). Pre-COVID and COVID-ve groups were matched 2:1 (age, sex and care service) with the COVID+ve group.

SETTING

One quaternary and two tertiary adult, acute care hospitals in Ottawa, Canada.

PARTICIPANTS

Decedents (n=425): COVID+ve (n=85), COVID-ve (n=170) and pre-COVID (n=170).

MAIN OUTCOME MEASURES

End-of-life (last 48 hours) in-person family presence and virtual (video) patient-family communication, and end-of-life (last 5 days) virtual team-family communication encounter occurrences were examined using logistic regression with ORs and 95% CIs. End-of-life (last 5 days) rates of in-person and telephone team-family communication encounters were examined using mixed-effects negative binomial models with incidence rate ratios (IRRs) and 95% CIs.

RESULTS

End-of-life in-person family presence decreased progressively across pre-COVID (90.6%), COVID-ve (79.4%) and COVID+ve (47.1%) groups: adjusted ORs=0.38 (0.2-0.73) and 0.09 (0.04-0.17) for COVID-ve and COVID+ve groups, respectively. COVID-ve and COVID+ve groups had reduced in-person but increased telephone team-family communication encounters: IRRs=0.76 (0.64-0.9) and 0.61 (0.47-0.79) for in-person, and IRRs=2.6 (2.1-3.3) and 4.8 (3.7-6.1) for telephone communications, respectively. Virtual team-family communication encounters occurred in 17/85 (20%) and 10/170 (5.9%) of the COVID+ve and COVID-ve groups, respectively: adjusted OR=3.68 (1.51-8.95).

CONCLUSIONS

In hospitalised COVID-19 pandemic wave 1 decedents, in-person family presence and in-person team-family communication encounters decreased at end of life, particularly in the COVID+ve group; virtual modalities were adopted for communication, and telephone use increased in team-family communication encounters. The implications of these communication changes for the patient, family and healthcare team warrant further study.

Grief Experiences of Families of Individuals Who Died Due to Coronavirus Disease-19: A Qualitative Study

The fear of contracting the disease, introduction of practices such as quarantine, social isolation, and curfew to prevent its transmission, and effects of experiencing a loss due to this disease are experienced differently by different people. The empirical phenomenological approach will be used to describe, explain, and analyze the experiences of the family members of individuals who lost their lives due to COVID-19. This study was created in accordance with COREQ Statement Checklist. The themes obtained from the interviews are "death in isolation", "changing cultural-religious practices that cannot be performed", "not being able to say goodbye".This transformed grieving process caused by the pandemic may create unique psychosocial needs among family members. To meet these needs, planning and organizing complex grief therapy, speech therapies, expressive supportive counseling, and grief recovery programs is recommended.

Young People's Experiences of Death Anxiety and Responses to the Covid-19 Pandemic

Capacity for death awareness and death anxiety in young people has been previously documented but the impact of Covid-19 is not currently known. Therefore, the aim of this study of this study was to explore young people's experiences and responses to the Covid-19 pandemic. Qualitative data was collected from young people via a two-stage process across the United Kingdom: Stage One consisted of an online questionnaire; Stage Two comprised online semi-structured interviews. Responses for Stage One of the study totalled 120 young people; 9 of these were interviewed for Stage Two of the study. Thematic analysis of data identified four themes relating to young people's experiences of the Covid-19 pandemic: death anxiety; mental health; normalising death; and identified support needs. Young people experienced heightened death anxiety due to the pandemic but death also became normalized for them and their mental health was negatively affected.

Family-centred care of patients admitted to the intensive care unit in times of COVID-19: A systematic review

OBJECTIVES

To describe clinical practice interventions aimed at providing Family-Centred Care in intensive care units during the COVID-19 pandemic.

RESEARCH METHODOLOGY

A systematic review was carried out following the PRISMA recommendations in various databases: PubMed, Cinahl, Web of Science, Scopus, and Google Scholar were consulted, as well as within the grey literature found on the web pages of official organizations related to Intensive Care Medicine and Nursing.

SETTING

Adult intensive care unit.

RESULTS

The search yielded 209 documents of which 24 were included in this review: eight qualitative studies, seven protocols and recommendations from official bodies, one mixed-method studies, five descriptive studies, one cross-sectional study, one pilot program and one literature review. A thematic analysis revealed four major themes: the use of communication systems, multidisciplinary interventions; the promotion of family engagement and family support. The results show different strategies that can be implemented in clinical practice to solve the difficulties encountered in Family-Centred Care in critical care units during the COVID-19 pandemic.

CONCLUSIONS

There is a great variety in the nature of the interventions developed, with the use of telecommunication systems in daily practice being the most repeated aspect. Future research should aim to assess whether the interventions implemented increase the quality of patient and family care by meeting their needs.

A Scoping Review of Interventions for Family Bereavement Care during the COVID-19 Pandemic

The death of a loved one is a major stressor, and bereaved people are at a higher risk of negative health effects. This risk is higher during the COVID-19 pandemic, which raises the need for understanding existing bereavement support interventions. This scoping review aimed to map and summarize findings from the existing literature regarding bereavement support interventions (i.e., psychosocial and psychotherapeutic interventions) for family carers of people who died of COVID-19. The Arksey and O’Malley methodological framework was used. Five databases—Medline, PubMed, CINAHL, Scopus, and Web of Science—were searched for articles available from the inception of COVID-19 pandemic (March 2020) to January 2022, following the PRISMA guidelines. Among the 990 studies identified, only seven met this study’s inclusion criteria. The analysis comprised three key topics: types of support programmes and bereavement interventions; tools used to measure the outcomes; and evidence of the impacts of the interventions. All studies analysed included interdisciplinary interventions, commonly developed in clinical settings. Support for recently bereaved individuals can entail cognitive behavioural therapy strategies and other tools to educate, guide, support, and promote healthy integration of loss. To mitigate the effects of non-normative family bereavement, we recommend a systematic approach and coordination between organizational settings, including access to informal and professional support, in order to find hope while navigating the aftermath of COVID-19.