'We didn't want him to die on his own' ? nurses' accounts of nursing dying patients

Breaking significant news: The experience of clinical nurse specialists in cancer and palliative care

PURPOSE

The aim of the research was to explore specialist cancer and palliative care nurses experience of delivering significant news to patients with advanced cancer.

METHOD

A qualitative phenomenological research study was conducted to capture nurses' experiences with the aim of understanding how cancer and palliative care clinical nurse specialists work towards disclosure of advanced and terminal cancer. Data were collected through semi-structured interviews with 10 clinical nurse specialists working in one acute NHS trust. Clinical nurse specialists were recruited from the following specialities: lung cancer, breast cancer, gynaecological cancer, upper and lower gastrointestinal cancer and palliative care.

RESULTS

Four themes emerged from the data: importance of relationships; perspective taking; ways to break significant news; feeling prepared and putting yourself forward. The findings revealed that highly experienced clinical nurse specialists (CNSs) felt confident in their skills in delivering significant news and they report using patient centred communication to build a trusting relationship so significant news was easier to share with patients. CNSs were aware of guidelines and protocols for breaking significant and bad news but reported that they used guidelines flexibly and it was their years of clinical experience that enabled them to be effective in disclosing significant news. Some areas of disclosure were found to be challenging in particular news of a terminal prognosis to patients who were of a younger age.

CONCLUSION

CNSs have become more directly involved in breaking significant news to those with advanced cancer by putting themselves forward and feeling confident in their skills.

Truth-telling in clinical practice and the arguments for and against: a review of the literature

In general, most, but not necessarily all, patients want truthfulness about their health. Available evidence indicates that truth-telling practices and preferences are, to an extent, a cultural artefact. It is the case that practices among nurses and doctors have moved towards more honest and truthful disclosure to their patients. It is interesting that arguments both for and against truth-telling are established in terms of autonomy and physical and psychological harm. In the literature reviewed here, there is also the view that truth-telling is essential because it is an intrinsic good, while it is argued against on the grounds of the uncertainty principle. Based on this review, it is recommended that practitioners ought to ask patients and patients' families what informational requirements are preferred, and research should continue into truth-telling in clinical practice, particularly to discover its very nature as a cultural artefact, and the other conditions and contexts in which truth-telling may not be preferred.

Training programme in techniques of self-control and communication skills to improve nurses' relationships with relatives of seriously ill patients: a randomized controlled study

The interpersonal relationships with relatives of seriously ill patients may cause anxiety on the part of nurses and the need for adequate communication and self-control skills. To assess the efficacy of training nurses in self-control techniques and communication skills when they interact with relatives of seriously ill patients we planned a randomized, controlled trial in two parallel groups: an experimental group, with immediate training, and a control group, with training delayed for 6 months. We recruited 61 nurses from the nursing staff of a university hospital of 500 beds. The intervention consisted of training in relaxation, cognitive restructuring and some communication skills. The outcome variables were communication skills measured under simulated conditions using an observation instrument of our own, administered by observers masked with respect to the study groups, and the levels of state-anxiety measured with the self-assessment questionnaire the State-Trait Anxiety Inventory, under imaginary conditions. The two groups initially had similar scores in the scales of communication skills, and state and trait-anxiety. After intervention, compared with the control group, the experimental group showed significant improvements in the skills of listening, emphasizing, interrupting and coping with emotions (P < 0.05). State-anxiety levels did not show any changes. In conclusion, the joint training in self-control and communication improves some communication skills in nurses when they interact with relatives of seriously ill patients under simulated conditions.

The importance of 'knowing the patient': community nurses' constructions of quality in providing palliative care

This paper reports findings from a study conducted in one community health care trust where 62 members of the district nursing team (grades B-H) were interviewed. An adaptation of the critical incident technique was used to determine factors which contributed or detracted from high quality care for a number of key areas including palliative care. The centrality of knowing the patient and his/her family emerged as an essential antecedent to the provision of high quality palliative care. Factors enabling the formation of positive relationships were given prominence in descriptions of ideal care. Strategies used to achieve this included establishing early contact with the patient and family, ensuring continuity of care, spending time with the patient and providing more than the physical aspects of care. The characteristics described by the community nurses are similar to those advocated in 'new nursing' which identifies the uniqueness of patient needs, and where the nurse-patient relationship is objectified as the vehicle through which therapeutic nursing can be delivered. The link with 'new nursing' emerges at an interesting time for community nurses. The past decade has seen many changes in the way that community nursing services are configured. The work of the district nursing service has been redefined, making the ideals of new nursing, for example holism, less achievable than they were a decade ago. This study reiterates the view that palliative care is one aspect of district nursing work that is universally valued as it lends itself to being an exemplar of excellence in terms of the potential for realizing the ideals of nursing practice. This is of increasing importance in the context of changes that militate against this ideal.

Striving for becoming at-home in the midst of dying

Research interviews with 12 patients at an inpatient, free-standing hospice in Sweden were analyzed, using a phenomenological hermeneutic approach, to show the effects of individual nursing care as experienced by the guests. The findings revealed that the effects of, and reactions to, nursing care were inseparable from the hospice milieu and the patients' situation, which was interpreted as including the prospect of becoming homeless. Thus, the effects of hospice spirit (nursing care and milieu) as experienced by these hospice patients represented the contrasting possibilities of hindering--or contributing to--the prospect of becoming homeless. What the patients spoke about was either a consoling or a desolating hospice spirit. A consoling hospice spirit supports experiences of wholeness and communion, i.e., becoming at-home in the midst of dying, while a desolating hospice spirit results in feelings of alienation and fragmentation, i.e., feeling homeless. Considering the dying person to be a guest rather than a patient is an important component of Swedish hospice philosophy and supports the view of the dying person as an autonomous and dignified human being.

How patients spend their time in a hospice and in an oncological unit

This paper presents the findings from a work sampling study. At 10-minute intervals the activities of patients in a hospice, and in an oncological unit were monitored for a day or a night. In total, 5286 observations of patient activities were recorded. The findings showed that being a patient, especially in the oncological unit, was apparently a very lonely experience with limited social interaction and purposeful activity. Hospice patients, in contrast, were less alone, spending much of their time with their relatives. Although none of the patients at either site spent a major part of either day or night with nurses, hospice patients and nurses spent significantly more time together, and their encounters more often lasted longer. Nursing care at both sites was mainly related to 'doing' rather than 'being', i.e. when with patients, nurses most often had some task to accomplish. The study shows the importance of increasing our understanding of the use of time and the combination of doing and being that reflects good nursing care of the dying.

A comparison of the verbal interactions of qualified nurses and nursing auxiliaries in primary, team and functional nursing wards

The purpose of this study was to compare the differential contribution to patient care of qualified nurses and nursing auxiliaries in primary, team and functional nursing wards using a measurable qualitative indicator, nurse-patient verbal interaction. Twelve qualified nurses and 12 nursing auxiliaries were chosen randomly in each organizational type. Data were collected using non-participant observation and a computerized event recorder. Regardless of staff grade, nursing staff in wards practising primary nursing gave patients more choice, general explanations about their care and, in the afternoon, spent more time seeking verbal feedback from patients about their care. Implications of these findings for the employment of nursing auxiliaries in elderly care wards are discussed.

Communication with dying patients in coronary care units

There now seems to be a much greater willingness among hospital staff to disclose a terminal prognosis to a patient. The paper starts with a review of the changing attitudes towards disclosure and then considers communication with dying patients in Coronary Care Units. After considering general factors influencing nurse communication with dying patients sources of difficulty in such communication are considered. Characteristics of patients and relatives, of nurses, and features of the work environment may all contribute to communicational difficulties. The paper closes with a brief overview of basic communicative requirements.

Communication and awareness about death: a study of a random sample of dying people

The literature suggests that doctors' and nurses' openness about communicating with the terminally ill and their families has increased in the past two or three decades, partly influenced by the hospice movement. The present study reports the perceptions of relatives, hospital doctors, general practitioners and nurses who knew a random sample of 639 adults dying in England in 1987. The results from professionals suggest a general preference for openness about illness and death, tempered by the consideration that bad news needs to be broken slowly, in a context of support, while recognising that not everyone wishes to know all. In practice people dying from cancer were more likely to be reported as knowing what their illness was and that they would die than were people dying from other conditions. This difference held when controlling for the fact that death was more likely to be medically expected in cancer. Comparisons with 1969 show that the increases were due largely to cancer patients being told the truth more frequently by hospital doctors. This may be due to changed practices, or to the increase in the number of hospital episodes in the last year of life. Nevertheless, situations of 'closed awareness' where relatives were told and patients were not, and situations where patients were left to guess the likely outcome for themselves, were still quite common in 1987. Nurses and hospice practitioners were only marginally involved in breaking bad news, this remaining the province of hospital doctors and general practitioners. Relatives in general praised the manner in which they and patients were told, although a small proportion reported insensitive practice. In retrospect a high proportion of both relatives and professionals felt that the levels of awareness were best as they were, although this preference may have been influenced by a desire to see things in a good light. Most relatives reported adequate support and information being given by professionals to them during the patient's illness. On the whole, doctors provided information, and friends and family provided emotional support to relatives. Again, hospital doctors played an increasingly important role compared to 1969 in providing information, with general practitioners' role decreasing in this area. Gaps in information included not being told enough about what was wrong with the patient, not being told the reasons for decisions about treatment and, to a lesser extent, not being given information about how to care for the patient.

Research on nurse-patient relationships: problems of theory, problems of practice

Research, theoretical and educational literature on interpersonal relations between nurses and patients has proliferated since the 1960s. This has generated a range of divergent accounts of what the nurse-patient relationship (NPR) ought to be; how this should be achieved; and how the NPR is constituted in practice. In this paper--through a selective review of the literature--the development of two contending perspectives on NPR and on nurse-patient interaction (NPI) characterized as technocratic and contextual, is discussed, and related to the increasingly problematic status of the relationship between nurses and patients in nursing theory and research.

Nurse's accounts of nursing the terminally ill on a coronary care unit

This paper is based on nurses' reported experiences about nursing people dying in a coronary care unit, and their attitudes towards such work. Two patterns of dying associated with cardiac arrest and cardiac failure were typical in the unit, each with its difficulties and problems. However, the nurses did not report any severe coping difficulties associated with their nursing care of dying patients. Their most severe difficulties were those relating to telling relatives about a patient's death. Elements within the unit's ethos and organisation associated with this positive coping were the high staff-patient ratio, low staff turnover, good and supportive relationships among staff, and the policy of open and honest communication about prognosis. Of particular importance was the feeling that everything that it was possible to have done for the patient had been done.

What happens in hospices: a review of research evidence

The growth of the modern hospice movement has been accompanied by some evaluative research, although this has been pursued with greater vigour in the United States than in Britain. Most studies employ the method of outcome measurement (patient or carer satisfaction for example) and only incidentally report on processes occurring within hospices or hospitals. A review of the research evidence suggests that processes of patient care may not always be very different between hospices and hospitals. This may be because hospital staff have learned from the example of hospices, but may also be due to hospice staff associated with traditional care systems compromising their ideals. Evidence from evaluative and from participant observation studies is reviewed to examine differences between hospital and hospice care in five major areas: medical therapies, psychosocial care, disclosure of prognosis, carers' involvement, in-patient care and relations between staff. The quality and scope of the research evidence in many instances needs extending. The relevance of a hospice approach to non-cancer patients is discussed and priorities for future research on the process of hospice care are outlined.

Stressful episodes reported by first-year student nurses: a descriptive account

This article examines stressful episodes reported by student nurses (N = 150) interviewed during the early stages of their training at two general hospitals. The approach is qualitative rather than empirical, and the paper focuses on how students perceive and interpret the day-to-day demands and frustrations they encounter in the course of their work in the wards. The episodes were classified into six major content areas. Three of these (the care of dying patients; interpersonal conflicts with other nurses; and insecurity about professional skills and competence) were found to account for two-thirds of the total episodes reported. The types of episodes are discussed in the context of literature findings relating to nursing stress. Underlying factors common to many episodes were the inadequate support and guidance given by senior nurses and clinical tutors, coupled with the students' lack of experience and the demanding nature of the ward environment. Ways in which adverse effects of stress among student nurses might be alleviated, including improving communication skills, enhancing social support, and the use of stress management techniques, are discussed in the light of this material.

Formal instruction in United Kingdom medical schools about death and dying

The paper reports the findings of a short questionnaire survey of medical schools conducted in June 1983. All U.K. schools replied. Only four schools do not provide formal instruction about death and dying for all their students.