Mediating conflict and control: practice challenges for nurses working in palliative care

Accounts of Family Conflict in Home Hospice Care: The Central Role of Autonomy for Informal Caregiver Resilience

End-of-life caregiving is a highly stressful experience often fraught with conflict and tension. However, little is known about the ways family conflict manifests for informal caregivers of home hospice patients (IHCs). Framed by relational dialectics theory, the purpose of this study was to provide nurses and other health care professionals with an empirical understanding of how IHCs experience family conflict and tensions associated with caregiving. A second aim was to determine what strategies IHCs use to manage these family conflicts. Data used in this qualitative secondary analysis were originally collected as part of a randomized clinical trial of an IHC support intervention. Based on thematic analysis of data from 25 IHCs who reported family conflict, a conceptual model of caregiver resilience was developed from the themes and categories that emerged during the coding stage. Autonomy was identified as a central tension. IHCs used several strategies to address family conflict including communication, formal support, and emotional self-care.

Conflict of roles: a conflict of ideas? The unsettled relations between care team staff and independent mental health advocates

Drawing on a national study of independent mental health advocacy, we explored the social relations of independent advocacy. The study was commissioned by the Department of Health (England), and involved a case study design covering eight different geographies and service configurations, and interviews or focus groups with a total of 289 stakeholders across two phases of inquiry. This paper focused on the analysis of qualitative data relevant to the relationship between mental health-care services and independent advocacy services, drawn from interviews with 214 participants in phase two of the study. Discussion of these particular findings affords insights into the working relations of independent advocacy within mental health services beset by reorganizational change and funding cuts, and increasing levels of legally-sanctioned compulsion and coercion. We offer a matrix, which accounts for the different types of working relationships that can arise, and how these are associated with various levels of understanding of independent advocacy and appreciation for the value of advocacy. The discussion is framed by the wider literature on advocacy and the claims by practitioners, such as nurses, for an advocacy role as part of their professional repertoire.

Advancing theory of family conflict at the end of life: a hospice case study

CONTEXT

Although family conflict is a common occurrence for families involved in caregiving for a dying family member, it has not been examined in the hospice context.

OBJECTIVES

The purpose of this study was to advance theory of family conflict at the end of life through replication and expansion of a case study involving professional perspectives in the context of a managed care program for low-income elders with advanced chronic disease in their last six months of life, by exploring the perceptions of professionals and family caregivers experiencing conflict in the hospice context.

METHODS

Data were gathered through in-depth interviews with 15 hospice family caregivers experiencing substantial family conflict, and focus groups with 37 professionals employed in a large multicounty and nonprofit hospice in the Midwest U.S. Dimensional analysis, a method for the generation of grounded theory, was used to refine and expand an explanatory matrix of family conflict at the end of life.

RESULTS

The initial matrix was expanded through the inclusion of eight new and two refined categories, strengthening our understanding of family conflict as a complex phenomenon influenced by salient contextual variables, conditions, and factors that may contribute to a number of negative outcomes for patients, family members, and professionals.

CONCLUSION

The study findings are discussed in terms of implications for assessment and intervention.

Disruption of parent participation: nurses’ strategies to manage parents on children's wards

AIMS AND OBJECTIVES

To investigate parent participation in the hospitalized child's care from the perspectives of children, parents and nurses.

BACKGROUND

Parent participation in the hospitalized child's care has been increasingly promoted in paediatric nursing for many years because it ameliorates the adverse aspects of hospitalization, avoids parental separation and contributes to quality care for sick children. Parent participation is assumed to be unproblematic but evidence exists that nurses often have difficulty caring for parents.

DESIGN

Using grounded method, data were collected through in-depth interviews, questionnaires and observation with 12 nurses from four paediatric wards in two hospitals in England.

RESULTS

The dominant process appeared to be the socialization of parents to their role on the ward through inclusionary and exclusionary tactics. Nurses controlled the nature of parents' participation and parents had to 'toe the line'. Although participation was presented as optional, parents were presented with no course other than acceptance. Parents were expected to stay with their child, behave properly and be involved in care. When parents did not adhere to these norms, they caused disruption to the order and routine of the ward. Compliance or non-compliance to the set of norms and rules was followed by reward or punishment.

CONCLUSION

The nurses' dependence on parents' active participation in the organization and delivery of the work suggests that parent participation as it is practised is clearly about administrative efficiency, not consumer empowerment.

RELEVANCE TO CLINICAL PRACTICE

Organizational and managerial issues must be examined to ensure that nurses are adequately prepared and resourced to support parents on the ward. Continuing assessment of parents' expectations though a structured assessment tool would help reduce misunderstandings and conflict. Nurses should assess the situational context before relying on subjective impressions and assumptions about parents' participation in care.

Death and Dying in Nursing Homes: A Burden for the Staff?

Changes in our society increasingly place the old and impaired in institutions, where they spend their last remaining days. The authors explore the burden of being confronted with death and dying on nursing home staff using mixed methodology. Findings from open-ended interviews with 17 representatives of different occupational groups inform the design of a questionnaire used to conduct a survey in 52 nursing homes of the Federal Province of Carinthia (Austria). In total, 894 questionnaires were returned, yielding a response rate of 49%. Results indicate that it is more difficult to talk about death with family members of terminally ill residents than with the dying themselves. The need for end-of-life training is not only essential for nursing staff but is also needed for nonnursing staff, who are found to be substantially strained by aspects of death and dying in their workplace.

Complex Pain Consultations in the Pediatric Intensive Care Unit

The assessment and management of pain in children is not always easy and it is clearly more difficult in the critical care setting. Pain management is further complicated in this vulnerable population by the nature of their critical condition, the complexity and multidimensionality of their illness or injuries, and the intensity of emotions in this environment. A variety of pain syndromes are encountered in the pediatric intensive care unit, and the staff there may not be familiar with or comfortable managing these cases. Pain assessment and treatment can be more appropriately managed when guided by the experts of a multidisciplinary pediatric pain service.

Everyday death: how do nurses cope with caring for dying people in hospital?

In the UK, policies on health recognise the importance of supporting healthcare professionals if they are to realise their potential for delivering quality services. Little is known about how nurses working in hospitals cope with caring for dying people and, hence how they might be best supported in this work. This paper reports a qualitative study informed by phenomenological philosophy, which developed a theory of how newly qualified nurses cope with caring for dying people in acute hospital medical wards. On the basis of the theory, interventions are proposed that could help support nurses in their work with dying people.

Being a palliative care nurse in an academic hospital: a qualitative study about nurses' perceptions of palliative care nursing

The original philosophy of palliative care emphasizes the importance of the integration of compassion and medical science. The meaning palliative care nurses assign to their relationships with patients has been described in several studies. This qualitative research was undertaken in order to elicit the way nurses working on a palliative care ward in an academic hospital perceive their role and gain insight into the problems they encounter. The findings present two different perceptions held by nurses about the nature of their work. The first, the more prominent, is 'striving to adopt a well-organized and purposeful approach as a nurse on an academic ward'; the second is 'striving to enhance the well-being of the patient'. Nurses should be supported in the development of their palliative care approach and be assisted in reflecting on their practice in terms of a model of 'reflective practice' and in the development of 'moral imagination'.

Moral problems experienced by nurses when caring for terminally ill people: a literature review

This article is a review of the literature on the subject of how nurses who provide palliative care are affected by ethical issues. Few publications focus directly on the moral experience of palliative care nurses, so the review was expanded to include the moral problems experienced by nurses in the care of the terminally ill patients. The concepts are first defined, and then the moral attitudes of nurses, the threats to their moral integrity, the moral problems that are perceived by nurses, and the emotional consequences of these moral problems are considered in turn. The results show that the moral behaviour of nurses, which is theoretically grounded in commitment to care and to the patient, appears to be shaped by specific processes that lead to engagement or to mental and behavioural disengagement in morally difficult situations. Nurses often appear to fail to recognize the moral dimensions of the problems they experience and also to lack the skills they need to resolve moral problems adequately. Although the findings show that several elements that are beyond the control of nurses, owing to their lack of autonomy and authority, influence their moral experience, intrinsic factors such as feelings of insecurity and powerlessness have a profound effect on nurses' perceptions and attitudes in the face of moral problems. The moral problems perceived by these nurses are related to end-of-life issues, communication with patients, the suffering of patients, and the appropriateness of the medical treatment.