Supporting Cancer Patients With Palliative Care Needs

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The work of palliative care from the perspectives of district nurses: A qualitative study

AIM

To explore the work of palliative care from the perspectives of district nurses with a focus on the strategies they use to achieve positive outcomes for patients.

DESIGN

An exploratory descriptive qualitative study.

METHODS

A combination of group and individual interviews using semi-structured interviewing were used to explore district nurses' views of providing palliative care across two large urban community nursing services.

RESULTS

Sixteen district nurse participants were interviewed. Three key themes were identified: "Getting what was needed" involved finding solutions, selling a story and establishing relationships. District nurses sought ways to "Stay involved" recognizing the benefit of delaying discharge for some patients. "Completing a nursing task" was a way of managing time constraints and a form of self-protection from having difficult conversations.

CONCLUSION

This study highlights the importance of understanding the contextual nature of the practice setting in relation to the provision of palliative care. In doing so, it has revealed the strategies district nurses use to overcome the challenges associated with providing palliative care within a generalist workload.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

District nurses experience a tension between managing high patient workloads and remaining patient centred in palliative care. Being task focused is a way of remaining safe while managing a high volume of work and is not always a negative factor in the care they provide. However, focusing on a task while at the same time addressing other unmet needs requires a set of skills that less experienced nurses may not have.

IMPACT

Palliative care education alone will not improve the quality of palliative care provided by generalist community district nurses. The practice context is an important factor to take into consideration when supporting the integration of palliative care in district nursing.

NO PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution was made to this study.

REPORTING METHOD

We have adhered to the relevant EQUATOR guidelines and used the COREQ reporting method.

Nursing activities for health promotion in palliative home care: an integrative review

Palliative care in community contexts is undergoing significant change as a result of public policy and new models of care, which link health promotion principles with palliative care practices. These models support the creation of partnerships between formal care structures and the communities in which care is provided. Given the central role of nurses in the institutional delivery of palliative care, particularly in the home, it is important to provide a systematic description of the activities of nurses that fall within the principles of health promotion. The objective was to describe the diverse range of nursing activities for health promotion that are provided in the palliative home care setting. This is an integrative review. Fifty-five studies listed in the MEDLINE, CINAHL and EMBASE databases, and published between 1999 and December 2022, were identified. Data analysis and presentation of the results were guided by Kellehear's Health-Promoting Palliative Care (HPPC) model. Six themes were identified to describe nursing activities for health promotion in the context of palliative home care: creating a meaningful relationship, supplying medical information, promoting self-care throughout the trajectory, providing emotional support, involving professional or community services and supporting change. The findings point to nurses focusing more on the individual context and on direct care. The relationship with communities in which they work remains unidirectional. However, some HPPC principles are relevant to nursing activities through the contextualization of nurses' actions and their moral responsibility to work towards the respect of patient's values. Being poorly described, how nurses can truly engage their practice towards health-promoting principles, such as the enhancement of support and control over their lives for people living with serious illness, still requires further empirical research.

The experiences and needs of nurses providing home-based palliative care: A qualitative meta-synthesis

Objective(s): We conducted a qualitative meta-synthesis of qualitative studies on nurses' experiences when caring for palliative patients to (1) identify the needs of nurses and (2) describe their experiences to provide more in-depth information. Methods: Qualitative articles published in English from 2000 to 2022 were identified from several databases through a searching strategy. Authors screened through the title, abstract, and full text of relevant studies. Articles were read repeatedly and discussed. The thematic analysis methodology was adopted to analyze the data. Results: Of 967 articles, 22 were included in our review. Notions reflecting community nurses providing palliative home care were clustered into four themes: (1) nature of community-based palliative nursing, (2) teamwork, (3) relationship with patient and family, and (4) resources. Findings also suggest establishing a sound support system, strengthening palliative education, and creating more decisive referral criteria and systems. Conclusions: The growing need for palliative home care has become challenging for community health care systems. Our study summarized various aspects of nurses providing home-based palliative care. The findings provide information for health care and education settings to improve home care systems and recruit more staff to meet the needs.

Voices lost: where is the person in evaluating a palliative approach to care?

Person-centredness is a cornerstone to a palliative approach to care. However, there is a risk that a person-centred perspective is lost in how a palliative approach is evaluated. We explored the extent to which evaluations of a palliative approach are consistent with its person-centred ethical stance. Using a narrative review approach, we critically reflected on how the experiences, priorities and concerns of patients and family are represented, or not represented, in evaluations of a palliative approach. We were guided by the following questions: (1) What types of outcomes and indicators are commonly used to evaluate a palliative approach? (2) Whose perspectives are represented in current evaluations of a palliative approach? And (3) What are the foci of evaluation in this body of research? We observed that the evaluations of a palliative approach are commonly based on indicators of its implementation and predominantly reflect the perspectives of healthcare providers and healthcare systems, rather than patients or family. Although evaluations focused on healthcare providers and systems are important for integrating a palliative approach, there is concern that the essence of person-centredness is lost when the perspectives of patients and families about their healthcare needs, outcomes and experiences are not consistently measured as the ultimate goal of care. There is a need for more emphasis on evaluation practices that value person-centred outcomes, in addition to outcomes oriented to the needs of healthcare providers and systems.

Understanding Complexity in Care: Opportunities for Ethnographic Research in Palliative Care

Background: Ethnography has been used to address a broad range of research questions in health care. With ethnographic research methods it is possible to gain access to the complex realities of health care practice as it occurs, through interpreting the nuances of individual and team behaviours, the roles and dynamics of care provision, and the social impacts and influences of illness. The provision of clinical palliative care is complex, involving multidisciplinary collaboration across different health systems, and is subject to a multitude of personal, cultural and environmental influences. This complexity demands creative methodological approaches to research in palliative care, of which ethnography plays an important, if infrequently utilised, role. Aim: This article aims to explore potential opportunities of ethnographic methods for palliative care research. Findings: Ethnographic methods focuses on behaviour in the 'natural' setting of participants, to create theoretical descriptions of events, cultures, interactions and experiences. In palliative care these methods may provide nuanced understandings of illness, relationships and teams, communication, medical education, complex care provision, and novel or changing health practices. Of particular importance is the potential of these methods to understand complex practices and processes, and engage with under-represented population groups who may be excluded from interview research. Conclusion: Ethnography offers important opportunities for future research in palliative care and should be considered as part of the 'research toolbox' to improve understanding of the complex nature of care provision and the experiences of illness and loss.

Person-centred communication for emotional support in district nursing: SAGE and THYME model

Patients on district nursing caseloads have multiple physical morbidities, and related emotional concerns. District nurses are ideally placed to assess and meet patients' emotional needs but in increasingly stretched workplaces, it is difficult to find time. There is also evidence that district nurses sometimes believe they lack skills to address patients' concerns. Traditional communication skills training is useful for encouraging patients to open up about their concerns, but less helpful at finding workable solutions. District nurses can be afraid to open a 'can of worms' of concerns that they are unable to deal with. SAGE and THYME is a person-centred, evidence-based communication skills model that addresses district nurses' concerns about time and skills. It provides a structure for conversations about concerns, and empowers patients to work with district nurses to find solutions. Research suggests that it is a promising model for district nursing practice.

Conceptual foundations of a palliative approach: a knowledge synthesis

Background

Much of what we understand about the design of healthcare systems to support care of the dying comes from our experiences with providing palliative care for dying cancer patients. It is increasingly recognized that in addition to cancer, high quality end of life care should be an integral part of care that is provided for those with other advancing chronic life-limiting conditions. A “palliative approach” has been articulated as one way of conceptualizing this care. However, there is a lack of conceptual clarity regarding the essential characteristics of a palliative approach to care. The goal of this research was to delineate the key characteristics of a palliative approach found in the empiric literature in order to establish conceptual clarity.

Methods

We conducted a knowledge synthesis of empirical peer-reviewed literature. Search terms pertaining to “palliative care” and “chronic life-limiting conditions” were identified. A comprehensive database search of 11 research databases for the intersection of these terms yielded 190,204 documents. A subsequent computer-assisted approach using statistical predictive classification methods was used to identify relevant documents, resulting in a final yield of 91 studies. Narrative synthesis methods and thematic analysis were used to then identify and conceptualize key characteristics of a palliative approach.

Results

The following three overarching themes were conceptualized to delineate a palliative approach: (1) upstream orientation towards the needs of people who have life-limiting conditions and their families, (2) adaptation of palliative care knowledge and expertise, (3) operationalization of a palliative approach through integration into systems and models of care that do not specialize in palliative care.

Conclusion

Our findings provide much needed conceptual clarity regarding a palliative approach. Such clarity is of fundamental importance for the development of healthcare systems that facilitate the integration of a palliative approach in the care of people who have chronic life-limiting conditions.

Improving communication with palliative care cancer patients at home - A pilot study of SAGE & THYME communication skills model

PURPOSE

To pilot an evidence-based communication skills model (SAGE & THYME) with UK District Nurses (DNs) who visit patients with advanced cancer early in the dying trajectory. Evidence suggests that DNs lack confidence in communication skills and in assessing cancer patients' psycho-social needs; also that they lack time. SAGE & THYME is a highly structured model for teaching patient centred interactions. It addresses concerns about confidence and time.

METHOD

Mixed methods. 33 DNs were trained in SAGE & THYME in a three hour workshop and interviewed in focus groups on three occasions: pre-training, immediately post-training and two months post-training. Questionnaires measuring perceived outcomes of communication, confidence in communication and motivation to use SAGE & THYME were administered at the focus groups.

RESULTS

SAGE & THYME provided a structure for conversations and facilitated opening and closing of interactions. The main principle of patient centeredness was reportedly used by all. Knowledge about communication behaviours helpful to patients improved and was sustained two months after training. Increased confidence in communication skills was also sustained. Motivation to use SAGE & THYME was high and remained so at two months, and some said the model saved them time. Challenges with using the model included controlling the home environment and a change in style of communication which was so marked some DNs preferred to use it with new patients.

CONCLUSION

Training DNs in SAGE & THYME in a three hour workshop appears to be a promising model for improving communication skills when working with cancer patients.

District nurse advocacy for choice to live and die at home in rural Australia: a scoping study

BACKGROUND

Choice to live and die at home is supported by palliative care policy; however, health resources and access disparity impact on this choice in rural Australia. Rural end-of-life home care is provided by district nurses, but little is known about their role in advocacy for choice in care.

OBJECTIVES

The study was conducted to review the scope of the empirical literature available to answer the research question: What circumstances influence district nurse advocacy for rural client choice to live and die at home?, and identify gaps in the knowledge.

METHOD

Interpretive scoping methodology was used to search online databases, identify suitable studies and select, chart, analyse and describe the findings.

RESULTS

34 international studies revealed themes of 'the nursing relationship', 'environment', 'communication', 'support' and 'the holistic client centred district nursing role.

DISCUSSION

Under-resourcing, medicalisation and emotional relational burden could affect advocacy in rural areas.

CONCLUSION

It is not known how district nurses overcome these circumstances to advocate for choice in end-of-life care. Research designed to increase understanding of how rural district nurses advocate successfully for client goals will enable improvements to be made in the quality of end-of-life care offered.

The development of a 7-day community specialist palliative care service

The author worked as a clinical nurse specialist (CNS) in community palliative care in the Central Lancashire area of England when the CNS service was extended to a 9am-to-5pm 7-day service. A project group was set up to canvas some of the key stakeholders for their views on the extension of the service. The group undertook a literature search, a telephone survey of services in other areas that were providing this level of service, and interviews to ascertain the views of district nurses in the locality of the proposed service extension. The extension of service has long been advocated and was one of the key recommendations in the UK Department of Health's peer-review process. Such an extension was implemented following the research phase and was then evaluated by the project lead and the community services manager. The extension was found to be effective in the ongoing monitoring and support of patients. Anecdotally, the CNS team also felt it had been proactive in preventing unnecessary hospital admissions, although this specific aspect is difficult to quantify. This article looks at how the service was developed, how it has evolved over time, and how it works today. Consideration is also given to benefits and limitations.

Early support visits by district nurses to cancer patients at home: a multi-perspective qualitative study

BACKGROUND

Many palliative cancer patients spend much of their last year at home. In the UK, district nurses make frequent support visits to patients and carers at this time, yet surprisingly little is known about their supportive role in palliative care. Current studies are limited to district nurses' reports of practice, which offer limited insight into their content. Patients' and carers' views on district nurse support visits are largely unknown.

AIM

To present findings of a multi-perspective study that explored how district nurse early support visits are both described and carried out.

DESIGN

Focus groups with district nurses to explore views on the purpose of early support visits. Observation of support visits to identify how they are conducted. Patient and carer interviews to elucidate and verify district nurse data.

SETTING AND PARTICIPANTS

Participants included 58 district nurses, 10 palliative care patients and nine carers from four Primary Care Trusts in contrasting urban and rural locations.

RESULTS

District nurses had difficulty articulating early support visits. Observations however revealed a complex role comprising extensive physical and practical assessments, practical interventions, information giving, liaison, facilitation and referral. Patients and carers confirmed that they felt valued, reassured and supported by district nurses.

CONCLUSIONS

A multi-perspective approach provided new insights into district nurse support visits. Monitoring work described appears to have additional psycho-social benefits for patients and carers. The supportive role of district nurses needs to be clearly articulated and recognised so that colleagues, patients and carers access this valuable resource for palliative care patients.

Evaluation of the Dignity Care Pathway for community nurses caring for people at the end of life

BACKGROUND

People nearing the end of life fear loss of dignity, and a central tenet of palliative care is to help people die with dignity. The Dignity Care Pathway (DCP) is an intervention based on the Chochinov theoretical model of dignity care. It has four sections: a manual, a Patient Dignity Inventory, reflective questions, and care actions.

METHOD

The feasibility and acceptability of the DCP were evaluated using a qualitative design with a purposive sample of community nurses. Data was collected from April to October 2010 using in-depth interviews, reflective diaries, and case studies and then analysed using framework analysis.

RESULTS

The DCP was acceptable to the community nurses, helped them identify when patients were at the end of life, identified patients' key concerns, and aided nurses in providing holistic end-of-life care. It requires the nurse to have excellent communication skills. Some of the nurses found it hard to initiate a conversation on dignity-conserving care.

CONCLUSION

The DCP helps nurses to deliver individualised care and psychological care, which has previously been identified as a difficult area for community nurses. All of the nurses wished to continue to use the DCP and would recommend it to others.

Using observation as a data collection method to help understand patient and professional roles and actions in palliative care settings

BACKGROUND

Observational research methods are important for understanding people's actions, roles and behaviour. However, these techniques are underused generally in healthcare research, including research in the palliative care field.

AIM

The aim in this paper is to place qualitative observational data collection methods in their methodological context and provide an overview of issues to consider when using observation as a method of data collection. This paper discusses practical considerations when conducting palliative care research using observation.

FINDINGS

Observational data collection methods span research paradigms, and qualitative approaches contribute by their focus on 'natural' settings which allow the explanation of social processes and phenomena. In particular, they can facilitate understanding of what people do and how these can alter in response to situations and over time, especially where people find their own practice difficult to articulate. Observational studies can be challenging to carry out: we focus on the potentially problematic areas of sampling, consent and ethics, data collection and recording, data management and analysis.

CONCLUSION

Qualitative observational data collection methods can contribute to theoretical and conceptual development and the explanation of social processes in palliative care. In particular this contribution to understanding care structures and processes should improve understanding of patients' experiences of their care journey and thus impact on care outcomes.

Nurses' needs in delivering palliative care for long-term conditions

This study addressed the question 'What are the needs of community nurses in delivering palliative care to people with long-term conditions?' A qualitative exploratory descriptive design was employed. Ten community nurses (Band 5-7) were recruited from a purposive sample following a process of randomised stratified sampling, according to geographical area and Band for matched numbers. Semi-structured interviews were undertaken and audio recorded with written informed consent. The interviews were transcribed verbatim and analysed using an adapted Burnard's framework. The study found that establishing therapeutic relationships, having access to resources, co-ordination and provision of clinical care and collaborative working were all highlighted by the community nurses as needs in delivering palliative care. If these four needs were met, the community nurses believed they could deliver palliative care to their patients. Issues around a lack of resources, community nurses' educational needs and the late referral of patients with non-malignant long-term conditions to community nursing were also identified.

Predictors of home death of home palliative cancer care patients: a cross-sectional nationwide survey

OBJECTIVES

To identify factors influencing the place of death among home palliative cancer care patients, focusing on the role of nurses in terms of pre- and post-discharge from hospital to home care settings.

DESIGN, SETTINGS AND PARTICIPANTS

A cross-sectional nationwide questionnaire survey was conducted at 1000 randomly selected homecare agencies in Japan. The questionnaires were completed by primary community nurses of home palliative patients just after their discharge. A total of 568 responses were analyzed (effective response rate, 69%).

RESULTS

Multivariate logistic regression analysis revealed the following independent factors of place of death among those patients: desire for home death at referral by both patient and family caregiver; caregiver relationship to patient as daughter or daughter-in-law; totally bedridden functional status of patient; patient not suffering from depression and/or anxiety at referral; patients and caregivers duly informed about the dying process/death in detail, as well as instructed by community nurses about pain management and how to treat/prevent bedsores in home care settings.

CONCLUSIONS

This study demonstrated the importance of both the hospital and community nurses' role in increasing the patients' chance of dying at home. Hospital nurses should support early transfer to home palliative care according to their assessment of the desire of patient/family caregiver for home death, the patients' clinical status, and caregivers' ability to provide patient care at home. Community nurses should inform patients/family caregiver in detail about the dying process/death just after discharge, relieve patient pain, treat/prevent bedsores, and instruct family caregivers on their symptom control.

Palliative care provision for older people in care homes

There is a paucity of research in relation to district nurses' (DNs) experiences of palliative care provision in adult care homes (CHs) despite their substantial involvement. The aim of this study was to demonstrate the current involvement of DNs in CHs and identify the potential implications for future practice in providing palliative care in this setting. The findings suggested that even experienced DNs, wanted support and education about when to commence palliative care. They also wanted earlier involvement with CH residents who have a life-limiting condition and CH managers were seen as being essential contributors towards planning care. There was concern among DNs as to how the Liverpool Care Pathway could be introduced into CHs with untrained carers and finally, DN alignment to CHs was shown to improve continuity of care for residents and produce more effective partnership working between DNs, general practitioners and CH staff.

Barriers to dying at home: the impact of poor co-ordination of community service provision for patients with cancer

For patients dying of cancer, there is an emphasis on giving choice regarding preferred location for care, with the option of dying at home, which is integral to UK government health initiatives such as the End of Life Care Programme. However, patients continue to be admitted to hospital in the terminal phase of their illness when they have expressed a desire to die at home. A qualitative study, using two audio tape-recorded focus group interviews, with a purposive sample of district nurses and community specialist palliative care nurses (19) was undertaken across two primary care trusts in the north west of England. Data were analysed using a thematic analysis approach. From a service provision perspective, the results reveal that poor discharge planning and co-ordination, difficulty in establishing additional equipment and services together with inadequate out of hours medical provision were all factors contributing to hospital admissions for patients with cancer in the last hours and days of life, and thus were barriers to dying at home.

Meeting the ongoing needs of survivors of rarer cancer

With more treatment options for people with cancer long-term survivorship is increasing. Physical and psycho-social needs have been identified in survivors of common cancers but very little has been written about the needs of patients with rarer cancers. Patients treated for rarer cancer are discharged to the primary health care team (PHCT), yet little is known about the assessment, management and support of these patients. Thirty-nine semi-structured interviews were conducted with (1) survivors of and (2) people living with rarer cancer (i.e. <5% of cancer burden). Participants were asked about physical and psycho-social needs and service provision. Data were analysed thematically using Atlas ti. Contrary to expectation, disease-free survivors of rarer cancer were indistinguishable from those living with disease in their ability to cope, and range of symptoms and needs. Participants with a clinical nurse specialist (CNS) reported that they were well supported on their return home and their needs were met. Participants without a CNS were referred to the PHCT who were unsure how to assess or support them. These participants felt abandoned. There is a need for the rehabilitation of patients with rarer cancer to strengthen individual coping mechanisms, and family and social support. Although there are resource and training implications, this is a potential role for the PHCT, district nursing in particular, and may lead to more focused and targeted provision of services.