“Beyond the Boundaries of Care Dependence”: A Phenomenological Study of the Experiences of Palliative Care Nurses

An exploration of the emotional impact of working in an adult hospice service for Irish healthcare professionals

PURPOSE

An ageing population and a global pandemic has placed greater demands on palliative care services. Numerous studies describe the patient experience in palliative care, however, few explore the healthcare professional's experience of caring in this setting. This study explored the emotional challenges faced by palliative care professionals working in adult hospice services in Ireland.

DESIGN/METHODOLOGY/APPROACH

A narrative phenomenological approach was adopted, using interpretative phenomenological analysis to analyse results from five participants' semi-structured interviews.

FINDINGS

The type of challenge experienced reflected the impact it had on the participant's emotional wellbeing. Challenges perceived as achievable contributed to high levels of emotional wellbeing. These challenges often offered the opportunity for skill development and elicited positive feelings. Challenges perceived as uncontrollable negatively impacted the professional's emotional wellbeing and increased their risk of burnout. Examples of this included the shift in service provision and professional expectations. The challenges palliative care professionals experience on a daily basis can negatively or positively impact their emotional wellbeing.

CONCLUSION

Overall, this study highlighted challenges and their impacts experienced by palliative care professionals, illustrating key areas for improvement to prioritise staff wellbeing.

Patients' and Nurses' experiences of caring in nursing: An integrative literature review across clinical practices

AIM

To summarise, interpret and synthesize research findings on patients' and nurses' experiences of caring in nursing across clinical practices.

BACKGROUND

Caring is a universal element of nursing; however, economic restrictions often negatively impact health services, and time shortages and limited numbers of staff may characterize care encounters. It is unclear how these contextual conditions affect patients' and nurses' experiences of caring.

DESIGN AND METHODS

This integrative literature review covers papers published between 2000 and 2022. Four databases-PubMed, PsycINFO (via Ovid), MEDLINE (via Ovid) and CINAHL (via EBSCO)-were systematically searched for eligible papers in May 2022. The included studies were critically appraised. Content analysis was performed to interpret and synthesize the findings. In accordance with the EQUATOR guidelines, the PRISMA 2020 and PRISMA-S checklists were used. An Integrative review methodology guided the process.

FINDINGS

In total, 33 studies were included in the review. Three themes captured the experiences of caring in nursing: (1) the complexity of the nursing care context, (2) the professionalism of the nurse, and (3) the trusting patient-nurse relationship.

CONCLUSION

The experience of caring in nursing depended on nurses' competence and discretion in the personal encounter framed by the nursing context. The caring relationship was based on reciprocity, but it remains asymmetrical, as the nurse had the power and responsibility to empower the patient. Barriers, such as increased demands for efficiency and resource scarcity, may hinder the experience of caring in nursing.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

By promoting an ongoing discussion of caring in nursing, nurse management can systematically support nurses in reflecting on their practice in diverse and complex clinical contexts.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution was made due to the study design.

'Thank you for loving me': A qualitative study on perceptions of gratitude and their effects in palliative care patients and relatives

BACKGROUND

Empirical studies suggest that gratitude positively influence the quality of life of palliative patients and relatives. However, the literature is marked by a lack of conceptual clarity about what gratitude is and whether it can bring about individual and social benefits.

AIM

This paper explores how palliative care patients and relatives understand gratitude, how discursive representations of gratitude may affect their positions, perceptions and relations, and how to conceptualise gratitude in the palliative context.

DESIGN

We examine 33 gratitude letters written by patients and relatives and 25 semi-structured interviews conducted as part of a pilot gratitude intervention study. We use a qualitative approach, thematic analysis, within a conceptual framework of discourse analysis.

SETTINGS/PARTICIPANTS

Data were collected from 23 patients and 13 relatives recruited through three hospital palliative care services in French-speaking Switzerland.

RESULTS

Participants articulate gratitude in five ways: (1) appreciating others; (2) love; (3) need to reciprocate; (4) appreciating the little things; (5) solace amid serious illness. While some of these representations are sources of positive emotions and outlook, wellbeing and hope, others may confirm self-perceptions of powerlessness and burden. These results support a tridimensional conceptualisation of gratitude in palliative care as source of individual benefits, valuing closest relationships and moral obligation.

CONCLUSION

Our study suggests that gratitude is a key to a good (end of) life, whilst highlighting potential negative effects. It could help healthcare professionals to better understand what gratitude means to patients and relatives, which may facilitate awareness and fostering of gratitude in palliative care.

Influencing factors of care dependence in patients with coronary heart disease after percutaneous coronary intervention-A cross-sectional study

AIM

Care dependence has been scarcely investigated in coronary heart disease patients after percutaneous coronary intervention. This study aimed to investigate the association between frailty, self-efficacy, combined effects of frailty and self-efficacy, mental health, and care dependence in coronary heart disease patients after percutaneous coronary intervention.

DESIGN

Cross-sectional study.

METHODS

Data from 400 patients after percutaneous coronary intervention were collected from 2017-2020. Logistic regression model and mediating analysis were used to identify the association between frailty, self-efficacy, combined effects of frailty and self-efficacy, and care dependence.

RESULTS

Patients with frailty and self-efficacy tended to have severe care dependence symptoms. There was no correlation between frailty symptoms, self-efficacy, and care dependence in patients without symptoms of anxiety or depression. But in patients with anxiety or depression symptoms, there is a strong correlation between frailty symptoms, lower self-efficacy, and care dependence. Mental health played an inhibitory effect on frailty and care dependence.

The Wounded Healer: A Phenomenological Study on Hospital Nurses Who Contracted COVID-19

Since the pandemic began nurses were at the forefront of the crisis, assisting countless COVID-19 patients, facing unpreparedness, social and family isolation, and lack of protective equipment. Of all health professionals, nurses were those most frequently infected. Research on healthcare professionals' experience of the pandemic and how it may have influenced their life and work is sparse. No study has focused on the experiences of nurses who contracted COVID-19 and afterwards returned to caring for patients with COVID-19. The purpose of this study was therefore to explore the lived personal and professional experiences of such nurses, and to describe the impact it had on their ways of approaching patients, caring for them, and practicing their profession. A phenomenological study was conducted with 54 nurses, through 20 individual interviews and 4 focus groups. The main finding is that the nurses who contracted COVID-19 became “wounded healers”: they survived and recovered, but remained “wounded” by the experience, and returned to caring for patients as “healers,” with increased compassion and attention to basic needs. Through this life-changing experience they strengthened their ability to build therapeutic relationships with patients and re-discovered fundamental values of nursing. These are some of the ways in which nurses can express most profoundly the ethics of work done well.

Palliative care organization and staffing models in residential hospices: Which makes the difference?

BACKGROUND

The number of patients using palliative care services, particularly residential hospices, is increasing. Policymakers are urging these services to reflect on the most effective organizational strategies for meeting patients' complex care needs.

AIM

To analyze the predictive power of staffing, structure and process indicators towards optimal control of patients' clinically significant symptoms over time.

DESIGN

Secondary analysis of data from a multicentre prospective longitudinal observational study (PRELUdiHO) collected between November 2017 and September 2018.

SETTING/PARTICIPANTS

Adult patients (n = 992) enrolled in 13 Italian residential hospices.

METHODS

Two generalized estimating equations logistic models were built, both with number of hospice beds and length of stay as independent variables as well as, in one case, patient-to-healthcare worker ratios, and, in the other, health professionals' qualification levels. Dependent variables were six not clinically significant (score<4) symptoms: pain, nausea, shortness of breath, feeling sad, feeling nervous, and 'how you feel overall', according to the Edmonton Symptom Assessment System revised (ESAS-r) scale.

RESULTS

The generalized estimating equations indicators on staff revealed the following 'optimal' model: Patient-to-Physician ratio (5.5:1-6.5:1); Patient-to-Nurse ratio (1.5:1-2.7:1); Patient-to-Nurse-Assistant ratio (4.1:1-6.3:1); with the most balanced staff composition including 19% physicians, 23% nurse assistants, and 58% registered nurses; hospice beds (12-25); length of stay (median = 12 days). This model predicted an up to four times greater likelihood of controlling all six ESAS-r symptoms over time. The generalized estimating equations model on the educational level of physicians and registered nurses showed that it was significantly associated with optimal patients' symptom control during the entire hospice stay.

CONCLUSIONS

This study showed the exact skill-mix composition and proportions of palliative care team able to ensure optimal control of patients' symptoms. The added value of physicians and nurses with a qualification in palliative care in terms of better patient outcomes reaffirmed the importance of education in guaranteeing quality care. Hospices with 12-25 beds, and recruitment methods guaranteeing at least 12-day stay ensured the most propitious organizational environment for optimal management of clinically significant symptoms. The transferability of these results mainly depends on whether the skills of health professionals in our `ideal' model are present in other contexts. Our results provide policymakers and hospice managers with specific, evidence-based information to support decision-making processes regarding hospice staffing and organization. Further prospective studies are needed to confirm the positive impact of this 'optimal' organizational framework on patient outcomes.

A Phenomenological Analysis of Experiences and Practices of Nurses Providing Palliative and End of Life Care

The aim of this study was to describe the experiences and practices of nurses providing palliative and end of life care. The study was conducted in the palliative care unit of a territory hospital in Turkey. The sample consisted of 11 nurses who had been working as palliative care nurses for at least one year. The face to face interview method was used to collect data, with a semi-structured in-depth individual interview. 5 main themes and 24 sub-themes were emerged in relation to the experiences and practices of the nurses. The majority of participant nurses pointed that inadequacy in the number of nurses, secondary nursing care activities, refusal of treatment, cultural and ethical problems were barriers in the provision of nursing care. They frequently experienced ethical issues when caring for end of life patients, and for this reason they felt the need for ethics counselling which they could consult.

What is the problem of dependency? Dependency work reconsidered

Dependency is fundamental to caring relationships. However, given that dependency implies asymmetry, it also brings moral problems for nursing. In nursing theory and theories of care, dependency tends to be framed as a problem of self-determination-a tendency that is mirrored in contemporary policy and practice. This paper argues that this problem frame is too narrow. The aim of the paper is to articulate additional theoretical 'problem frames' for dependency and to increase our understanding of how dependency can be navigated in practices of long-term care. It does so by way of an empirical ethical analysis of how care professionals tackle the problem of dependency in group homes for people with intellectual disabilities. The paper refers to these practices of mitigating the problem of dependency as 'dependency work', a phrase borrowed from Eva Kittay. The analysis of dependency work suggests that for care professionals, dependency is a threefold problem: one of self-determination, one of parity and one of self-worth. These findings suggest that patient autonomy cannot be a full solution to the problem of dependency in long-term care relations. But they also show that dependency as such is not a problem that can be solved, as attempts to mitigate it only serve to tighten the dependency relationship further. This is the paradox of dependency work.

Development and psychometric testing of the care dependence perception questionnaire

OBJECTIVE

This multicentre study aimed to develop a measure of the perception of care dependence in patients diagnosed with cancer and to test its psychometric properties.

METHODS

The questionnaire was developed based on findings emerged from a meta-synthesis and from qualitative studies conducted in three hospitals in Italy. The draft questionnaire was tested for face and content validity and pilot-tested with patients. The questionnaire was completed by care-dependent patients with cancer. Test-retest was conducted to verify stability. Exploratory factor analysis (EFA) was performed using a Maximum Likelihood robust estimator.

RESULTS AND CONCLUSION

The Scale-Content Validity Index was 0.92. The final 15-item questionnaire was completed by 208 patients admitted to two hospitals. The EFA yielded a two-factor model including a positive and a negative perception of care dependence. Factor score determinacy coefficients, Cronbach's alpha coefficients, composite reliability coefficients and Intraclass Correlations Coefficients yielded satisfactory results confirming internal consistency and stability. The hedonic balance score is also available as a single indicator of subjective well-being. The study provides initial validation of the Care DEeP Questionnaire that can be used by cancer nurses to assess positive and negative patient experiences with care dependence and to personalise and improve their care.

Reframing the meaning of life and professional values: A theoretical framework of facilitating professional care for terminally ill patients

Professional values reflect nurses' understanding of how to deliver professional care, which might influence nurses' attitudes and caring behaviors during end-of-life care. However, limited research has been conducted to explore nurses' experiences of professional development during end-of-life care, and theoretical explanations are scarce about how nurses enact their professional values during the caring process. This study explored the social process of professional values involved in end-of-life care in the Chinese cultural context by adopting a constructivist grounded theory approach. Twenty semi-structured in-depth interviews with 15 nurses from three hospitals in southeastern China were conducted. A theoretical framework emerged when focusing on the social process of "reframing the meaning of life and professional values" to facilitate professional care for terminally ill patients. Three main categories were sequentially identified as "recognizing the dilemmas when caring for terminally ill patients," "applying strategies to deal with values conflict," and "reconstructing values." This theoretical framework may be applied as a practical framework for equipping nurses with effective strategies to cultivate professional values, including the provision of adequate end-of-life knowledge, and a supportive workplace environment.