Home care nurses' decisions about the need for and amount of service at the end of life

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.

Systemic strengths and needs in palliative home care: exploring complexity

OBJECTIVE

We aimed to investigate the relationship between systemic strengths and complexity in home care of end-of-life patients.

METHODS

Quantitative descriptive longitudinal study of patients cared for at home by a palliative care team. Place of death was analyzed in relation to complexity, as determined by the HexCom complexity model after the initial home assessment. We used Pearson's chi-square test to analyze the comparison of proportions.

RESULTS

Forty-six hundred patients (74.4% oncologic) with a mean age of 76.2 years (SD 13.2) participated. Fifty-three percent had complete or severe functional dependence, 30.8% were already bedridden in the first assessment, and 59.7% died at home. Strengths influenced place of death, specifically exosystem (team) strength (OR: 4.07 [1.92-8.63]), microsystem (both patient 0.51 [0.28-0.94]) and caregiver (OR: 3.90 [1.48-10.25]), and chronosystem, related to prediction of progressive course (OR: 2.22 [1.37-3.60]).

CONCLUSIONS

To improve care for end-of-life patients and their families, a systemic view of dying and death that includes both needs and strengths is necessary. In this sense, the systemic framework proposed by Bonfrenbrenner can be useful for clinical practice.

Home care nurses facilitating planned home deaths. A focused ethnography

BACKGROUND

Home care nurses provide complex palliative care for patients who want to die in their own homes. This study aimed to explore home care nurses' facilitation of planned home death to better understand nursing practices.

METHODS

Data were collected between March 2019 and March 2020 using participant observations and semi-structured interviews. In addition, the number of planned home deaths was recorded. The analysis was guided by Roper and Shapira`s framework on focused ethnography.

RESULTS

Twenty home care nurses (three men) in eight home care areas in two Norwegian municipalities met the inclusion criteria. Eight home deaths were registered, seven participatory observations were performed, and 20 semi-structured interviews were completed. Home care nurses find facilitating planned home deaths to be rewarding work, to the point of going above and beyond. At the same time, they describe facilitating planned home deaths as demanding work due to organizational stressors such as staff shortages, heavy workloads, and time restraints. While they tend to patients' needs, they also express concern for the wellbeing of the next of kin. They find it challenging to juggle the needs of the patients with the needs of next of kin, as these are not always correlated.

CONCLUSION

Home care nurses are pushing the boundaries of their practice when facilitating planned home deaths while compensating for a fragile system by going above and beyond for patients and their next of kin. Providing insights into the work of home care nurses providing palliative care in patients' homes can impact recruiting and retaining nurses in the workforce and influence local practices and policies.

Communication Openings: A Novel Approach for Serious Illness Communication in Homecare

Serious illness communication in homecare about hospice and/or palliative care transitions is lacking due to clinical culture. The purpose of the current study was to understand communication openings using COMFORT™, a palliative care communication model used to train nurses. Qualitative, focus group interviews with 31 homecare nurses were conducted. Data were transcribed verbatim and thematically analyzed using NVivo software, followed by hand-sorting. Four themes for communication openings for initiating discussions about potential hospice and/or palliative care transitions were identified: Organizational Openings (homecare appropriateness, eligibility requirements, and staffing); Patient Openings (patient physical decline, psychosocial changes, safety concerns, and denying/stopping care); Caregiver Openings (caregiver physical changes and patient readiness); and Nurse Openings (need for hospice, checking for prognosis understanding, increasing interprofessional care needs, and providing end-of-life care). This study extends the concept of communication openings in the COMFORT model. Further development of communication openings as part of COMFORT communication is needed in educational and intervention research. [Journal of Gerontological Nursing, 49(11), 33-41.].

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.

Exploring home-based care nurses' mindset for nursing practices: a phenomenological study

Background

Home nursing is an essential aspect of healthcare and can address future health challenges. The nature of nursing and its practical applications are of particular interest, as nursing involves technical knowledge, rational procedures, and diverse skills. It is consequential to explore nursing practices in context to understand how nurses navigate their work. This study aimed to explore the characteristics of home care nurse practices and how nurses solve tasks in the context of nursing in home care.

Methods

This is an exploratory qualitative research study using a descriptive phenomenological approach. We reported following the COREQ guidelines. Fifteen in-depth interviews with nurses from four Norwegian municipalities were conducted and analysed according to stepwise inductive analysis.

Results

The analysis revealed three main patterns that characterise nursing practices in home care: ‘To be vigilant’, ‘To be an all-rounder’, and ‘To act with independence’. The content and distinction of these patterns are discussed through a theoretical framework of ‘clinical mindlines’. There are multiple mindlines and complex realities for home-based care nursing. The nurses displayed great sensitivity in their practice, were knowledgeable about where they focused their attention, adapted their actions to the context, and demonstrated their independence as professionals.

Conclusion

Nurses’ vigilance and contextual insight are critical to their practice approach and task-solving abilities. These professionals need to manage emergent organisations and exercise independence and professional judgment when adapting their work to the context of home care patients. Future health policy should not strictly be based on standardised guidelines; depending on the context, it is also appropriate to focus on nurses’ practical knowledge and the importance of mindlines.

[Factors associated with the hospital at home workload: A Delphi consensus study]

OBJECTIVES

To identify and prioritize a list of factors that contribute to the workload of the hospital at home (HaH) professionals.

MATERIAL AND METHODS

A qualitative methodology study performed between January and December 2019 in the 10 HAH units of the Basque Country. The data were obtained in 4phases: 1. Systematic literature search and review; 2. Expert group meeting; 3. Consensus method: Delphi technique (2 survey rounds) and nominal group meeting; 4. Meeting of the research team.

RESULTS

In the systematic literature search and review 85 factors were initially identified. These were reduced to 38 after the 8-person expert group meeting, in which 10 new factors were added. After the 2 Delphi rounds (106 and 57 professionals, respectively), 17 factors were maintained and 12 remained in doubt. The latter were evaluated at the nominal group meeting, consisting of 13 professionals who decided to eliminate 5 factors, include 3, and keep 3 as doubt. After the 8-person research team meeting, 14 potential factors were finally selected. They are related to the place of residence, the health state and social situation of the patients, as well as the health care provided at home.

CONCLUSIONS

The identified factors could serve for improving the organization and optimize the daily word of the HaH professionals.

Community Nurses' Preparations for and Challenges in Providing Palliative Home Care: A Qualitative Study

Hospitals have played a leading role in providing palliative care in Taiwan as its care model has developed over the past few decades. However, earlier local studies in Taiwan showed that terminal patients prefer to die at home, highlighting the need to promote community-based palliative care instead of hospital-based care. Along with this shift, how community nurses provide palliative home care merits further exploration. This qualitative descriptive study aims to understand (1) how community nurses implement community-based palliative care, (2) what preparations are needed, and (3) what challenges they may face. Purposive sampling was used for recruiting nurses. We conducted one-on-one, in-depth, semi-structured interviews. Interview recordings were transcribed verbatim and analyzed using thematic analysis. Eight community nurses with a range of experience in palliative home care were interviewed. Four major themes emerged: (1) Opportunities, (2) Qualifications, (3) Support, and (4) Commitments. Psychological preparedness, well-developed professional capabilities, external assistance, and peer support motivate community nurses to offer community-based palliative care. As the requests for palliative home care services increase, community nurses play a critical role in palliative home care. Although the sample size is small and the findings retrieved from a small number of experiences might not be generalized to every region, the study results could inform future experience-sharing and workshop sessions to train more nurses for community-based care, expanding service coverage, and providing optimal palliative care.

How nurses support family caregivers in the complex context of end-of-life home care: a qualitative study

Background

Family caregivers are crucial in providing end-of-life care at home. Without their care, it would be difficult for many patients to die at home. In addition to providing care, family caregivers also need support for themselves. Nurses could play an important role in supporting family caregivers, but little is known about if and how they do so. The aim of this study is to explore how nurses currently approach and support family caregivers in end-of-life home care and which factors influence their support of family caregivers.

Methods

Data were collected using semi-structured interviews with 14 nurses from nine home care organisations in the Netherlands, in 2018. Interviews were audio-taped, transcribed verbatim and analysed using a thematic analysis approach.

Results

We identified two underlying nursing perspectives on supporting family caregivers: an instrumental perspective (seeing family caregivers mostly as collaborative partners in care) and a relational perspective (seeing family caregivers as both providing and needing support). All the interviewed nurses stated that they pay attention to family caregivers’ needs. The activities mentioned most often were: identification of support needs, practical education, support in decision-making about the patient’s treatment, emotional support, and organising respite care, such as night care, to relieve the family caregiver. The provision of support is usually based on intuition and experience, rather than on a systematic approach. Besides, nurses reported different factors at the individual, organisational and societal levels that influenced their support of family caregivers, such as their knowledge and experience, the way in which care is organised, and laws and regulations.

Conclusions

Nurses tend to address family caregivers’ needs, but such care was affected by various factors at different levels. There is a risk that nursing support does not meet family caregivers’ needs. A more reflective approach is needed and evidence-based needs assessment tools may help nurses to systematically assess family caregivers’ needs and to provide appropriate support.

Psychometric evaluation of the German version of a social support scale of FAFHES (Family Functioning, Family Health and Social Support)

BACKGROUND

Family members often need to be supported in informal care of the elderly and desire to be involved into care planning and decision-making. Valid and reliable instruments are needed to measure how family members perceive the care and support they receive from nurses for older family members living at home.

AIM

The purpose of this study was to translate the 20-item social support scale of the Family Functioning, Family Health and Social Support (FAFHES) questionnaire from English to German and test the validity and reliability of the scale among Swiss-German-speaking family caregivers of home-dwelling elderly people who receive home healthcare services.

METHODS

A cross-sectional study was conducted to test the empirical and psychometric properties of the translated and culturally adapted version of the social support questionnaire. A factor analysis with the principal component analysis PCA was used to test construct validity. The internal consistency of items was measured with the Cronbach`s alpha coefficient.

RESULTS

After a rigorous translation process the original 20-item questionnaire was adapted into a 19-item version and tested with family caregivers (n = 207) of home-dwelling elderly. Psychometric testing of the German version of the social support questionnaire revealed that the three factors - affirmation, affect and concrete aid - were congruent with the original questionnaire. The accounted variance was 79.5% and the internal consistency determined by the Cronbach's alpha was 0.973.

CONCLUSION

The German version of the social support scale of the FAFHES questionnaire is a valid and reliable instrument to assess family perceived support on three dimensions - affirmation, affect and concrete aid - received from nursing professionals. The questionnaire should be tested further in other German-speaking populations.

Triaging the Terminally Ill-Development of the Responding to Urgency of Need in Palliative Care (RUN-PC) Triage Tool

CONTEXT

Evidence-based resource allocation is receiving increasing attention as we strive for equity, transparency, and cost-effectiveness across health care. In the context of finite resources, which of our patients with terminal illness should be prioritized for urgent palliative care?

OBJECTIVES

To develop the scoring system for the novel Responding to Urgency of Need in Palliative Care triage tool.

METHODS

Online international discrete choice experiment involving palliative care clinicians to establish the relative importance of seven key attributes of palliative care triage identified during an earlier qualitative study.

RESULTS

Participants (n = 772) were mainly female (79.9%) with a decade of clinical experience. All attributes contributed significantly (all P-values < 0.001) and independently to clinician assessment of urgency. This study found physical suffering (coefficient 3.45; 95% confidence interval: 3.24 to 3.66) was the most important determinant of urgency, followed by imminent dying (coefficient 1.56; 1.43 to 1.69), psychological suffering (coefficient 1.49; 1.37 to 1.60), caregiver distress (coefficient 1.47; 1.35 to 1.59), discrepancy between care needs and care arrangements (coefficient 1.14; 1.02 to 1.26), mismatch between current and desired site of care (coefficient 0.94; 0.85 to 1.03), and unmet communication needs (coefficient 0.84; 0.76 to 0.92).

CONCLUSION

Palliative care triage, which is complex and contextual, has been made more transparent through this discrete choice experiment. The Responding to Urgency of Need in Palliative Care triage tool provides an important step toward evidence-based assessment of priority for palliative care. Further research is underway to determine the validity of the tool in clinical practice and its impact on patient and caregiver outcomes.

Designing a Process Model of Home Care Service Delivery in Iran: A Mixed Methods Study

Background:

Considering the position of home health care in the current world, the objective of this study was to design an applied model of providing home care services in Iran.

Methods:

The mixed methods approach was employed in three stages in Iran from Feb 2015 to Sep 2016. During the first phase, the qualitative method of content analysis was used. Data were collected by conducting 26 individual interviews and holding one focus group session involving 7 people. Data analysis was based on Graneheim and Lundman’s approach to content analysis.

In the second phase of the study, a literature review was carried out and at the end of this stage, a preliminary model was designed. The model was standardized in the third phase using the Delphi method with 23 participants in two rounds.

Results:

In the first and second stages of the study, various categories emerged including patient referral, agreement, determination of the needed level of care, care plans designing, provision of comprehensive services, documentation, service monitoring, inter-professional cooperation, issuance of death certificates at home, ethical considerations, and the evaluation of services. Then, in the Delphi phase, 20 (95.2%) of the experts confirmed the structure and content of the model and its applicability.

Conclusion:

The designed model can be helpful in organizing the provision of integrated and comprehensive health services to clients at home, which can be effective in improving the clients’ health and enhancing their self-care and autonomy.

Nursing practice in home care: the mediation of care by reflexivity

OBJECTIVE

To analyze the practice of nurses in home care, considering the mediation of care by reflexivity.

METHOD

Unique, qualitative case study, anchored in the dialectical framework. The participants were 13 nurses who work in home care in Minas Gerais. Data were obtained by participant observation and interview, and submitted to critical discourse analysis.

RESULTS

Nursing care at home involves the repetitions of everyday actions and a degree of unpredictability. Reflexivity, according to Schön's theoretical framework, emerges as a component of professional practice that leads to the practice of care as a continuous assessment of work, and also to reflection on the challenges imposed by conflicting situations. Reflexivity also stems from professionals' search for improvements in their practices.

FINAL CONSIDERATIONS

We identified the presence of actions and knowledge mobilized by the reflexivity of the nurse in the home care setting. The following were the elements of this reflexive practice: knowing-in-action, reflection-in-action and reflection reflection-in-action.

An integrative review on family caregivers' involvement in care of home-dwelling elderly

Often family members provide care-giving, which allows older adults to remain in their homes. With declining health and increasing frailty, care-giving of elderly people becomes a task of family caregivers (FC) in conjunction with home care nurses. It has been shown in both acute care settings and long-term care facilities that family members prefer to be involved in decision-making and care planning for their next of kin. Therefore, an integrative review was conducted to explore the body of knowledge of FCs' involvement in home-care settings from the FCs' perspective. CINAHL, PubMed, and Cochrane databases was searched with the terms family caregiver, involvement, home care, and community dwelling. Studies written in German or English between 1996 and 2017 focusing on FCs' caring for home-dwelling older adults together with home care nurses were included and critically appraised. The extracted findings were analysed with concept analysis method. Twenty-six studies were included and five themes were identified. Four themes formed the basis of assistance towards family caregivers by nurses and included "relationship building with professionals," "negotiating with professional care," "being professionally supported," and "managing role expectations and knowledge sharing". The fifth theme, "working together" described the mutual care for the care recipient. Although the first four themes were consistent with a pre-existing conceptual model by Sims-Gould and Marin-Matthews (2010), the fifth required an expansion of the model with an additional contribution "collaborative practice". The findings illustrate that involvement in care is an interactional process, which provides the basis for collaborative practices with the home care nurses for family caregivers. Family members often want to be part of the healthcare team, and nurses need contextual factors that allow providing their full range of skills and knowledge to involve family caregivers accordingly.

The theory of a co-creative process in advanced palliative home care nursing encounters: A qualitative deductive approach over time

AIMS AND OBJECTIVES

The aim of this study was to test the theoretical conceptualization of the co-creative process in home care nursing encounters over time.

METHOD AND DESIGN

This was a multiple case study with a deductive analysis of qualitative data over time, using interviews and observations collected from three cases.

RESULTS

The co-creative process was complex and contained main, sub- and micro-processes. Time was important and valuable, giving the patient and relatives space to adjust the process to their own pace. Some processes were worked on more intensively in accordance with the patients' and relatives' needs, and these are considered the main-process. The further developed theory of the co-creative process and its main, sub- and microprocesses can be understood as a concretization of how good nursing care can be performed within caring relationships in the context of advanced palliative home care.

Adaptations and inventions in the praxis of nurses in home care: implications of the reflective practice

Abstract Objective: To analyze the praxis of nurses at home, considering their power to invent new ways of producing care. Methods: This is a Unique Case Study, with a qualitative nature, anchored in the theoretical-methodological framework of dialectics. It was attended by 13 nurses working in home care services in Minas Gerais State. Data were obtained through participant observation and interview, and then submitted to Critical Discourse Analysis. Results: The praxis of the nurse at home is shaped by the relationship of interdependence between theory and practice and of a practice built through adaptations and inventions entailed by the specific context of Home Care, as well as by the space where care happens. Conclusions and implications for practice: Adaptations and inventions represent the sensible action of nurses expressed during practice, with a view to transforming a reality. Moreover, they have a dialectical relationship between lack of resource and accomplishment of care.

Home health nurse decision-making regarding visit intensity planning for newly admitted patients: a qualitative descriptive study

Despite patients referred to home health having diverse and complex needs, it is unknown how nurses develop personalized visit plans. In this qualitative descriptive study, we interviewed 26 nurses from three agencies about their decision-making process to determine visit intensity and analyzed data using directed content analysis. Following a multifactorial assessment of the patient, nurses relied on their experience and their agency's protocols to develop the personalized visit plan. They revised the plan based on changes in the patient's clinical condition, engagement, and caregiver availability. Findings suggest strategies to improve visit planning and positively influence outcomes of home health patients.

Barriers to palliative care in people with chronic obstructive pulmonary disease in home care: A qualitative study of the perspective of professional caregivers

AIMS AND OBJECTIVES

To examine the experiences with palliative care in people with chronic obstructive pulmonary disease among professional caregivers in a Danish home care setting.

BACKGROUND

Many patients with advanced chronic obstructive pulmonary disease depend on professional caregivers in the primary sector to provide assistance and care. However, chronic obstructive pulmonary disease patients receive no or only very little palliative care compared to patients with cancer although they may have many burdensome symptoms.

DESIGN

Qualitative explorative study.

METHODS

In 2013-2014, ten professional caregivers from three districts in a Danish municipality were followed during home visits to patients with chronic obstructive pulmonary disease and individual interviews about palliative care were subsequently conducted. In 2014, 66 professional caregivers, representing eleven home care districts, participated in ten group discussions about palliative care needs in this group of patients. Data were analysed using qualitative descriptive analysis.

RESULTS

The study revealed a nonawareness of palliative care for patients with chronic obstructive pulmonary disease among the professional caregivers who expressed vague understanding of palliative care and lack of knowledge about the disease. Organisational barriers, such as lack of time and continuity in patient care, lack of opportunity to discuss palliative care and lack of peer learning were experienced as challenging in the provision of palliative care. Nonawareness and organisational barriers led to difficulties in identifying palliative care needs and reluctance to initiate conversations about palliative care.

CONCLUSION

The findings indicate a need for education, training and reflection among professional caregivers in home care. Also, organisational changes may be needed to reduce the barriers to palliative care.

RELEVANCE TO CLINICAL PRACTICE

The findings uncovered barriers to palliative care that must be addressed. Targeted educational programmes and organisational changes may increase the ability to identify palliative care needs and initiate and evaluate palliative interventions.

Atuação do enfermeiro na atenção domiciliar: uma revisão integrativa da literatura

RESUMO Objetivo: analisar a produção científica acerca da atuação do enfermeiro na atenção domiciliar em saúde. Método: realizou-se uma revisão integrativa da literatura por meio de consulta às bases de dados LILACS, BDENF, IBECS e MEDLINE. Foram incluídos estudos em espanhol, inglês e português, não delimitando data de publicação. Resultados: analisados 48 artigos, identificou-se que a atuação do enfermeiro na atenção domiciliar possui complexidade e diversidade de ações com uso de tecnologias leves, leve-duras especialmente, e duras. Destaca-se que desafios relacionados ao processo formativo para a atenção domiciliar estão relatados na literatura. O enfermeiro utiliza conhecimento experiencial e recomendações científicas aliados à reflexão na prática. Conclusão: a atuação do enfermeiro no espaço domiciliar é fundamental e ampla. As ações relacionais e educacionais se destacam, sendo necessárias inclusive nos cuidados técnicos, predominando a necessidade de formação para a atenção domiciliar.

Shining trinkets and unkempt gardens: on the materiality of care

The increasing use of telecare will profoundly change nursing care. How to understand these changes is, however, far from clear. This is because (i) studies on telecare seldom consider the situation it replaces, and (ii) current concepts and methods used to study the impact of telecare may not allow us to fully grasp these changes. We suggest that an analysis of the changing materiality of care practices is a suitable way to articulate and reflect on possible concerns. It allows us to compare care practices in the same terms before and after telecare has been introduced. To demonstrate this, we study the materiality of the classical care setting, the nursing house call, to map the situation before telecare is introduced. Building on science and technology studies, we apply four categories as heuristics to analyse materiality in care: signs, dis/enablers (or scripted things), tools and practical arrangements. We leave open the question of how material arrangements could or should be matters of concern in nursing care, and instead argue for studies that give insights into the everyday tinkering with the materiality of care that both nurses and patients need to engage in.

Applying research into practice: a guide to determine the next palliative home care nurse visit

Beyond their own family caregivers, home healthcare nurses play a pivotal role in caring for those dying at home. However, deciding the timing of the next visit for these patients and their families is not straightforward. The Palliative Care: Determining Next Home Care Nurse Visit decision guide supports clinicians in their decision-making process of planning visits to most effectively meet the needs and goals of patients and families during the final months of life.

Nurse Practitioner Mental Health Care in the Primary Context: A Californian Case Study

In America, mental health needs surpass the availability of specialized providers. This vulnerable population also has other obstacles for comprehensive care including gaps in medical coverage, stigma, economic barriers, and a geographical mal-distribution of qualified mental health professionals. A wide availability of primary care providers, including primary care and family nurse practitioners, are well-positioned to deliver integrated mental and physical health care. A case study from a Southern California Coachella Valley primary care clinic with integrated services is used to demonstrate the much-needed approach of care to address health disparities that face low-income immigrants, migrant workers, and others without access to specialized care centers and providers. It is argued that mental health care should be part of all holistic treatment provided by primary care and family nurse practitioners. This has implications for curricula and practice development.

Validation of a new instrument for self-assessment of nurses' core competencies in palliative care

Competence can be seen as a prerequisite for high quality nursing in clinical settings. Few research studies have focused on nurses' core competencies in clinical palliative care and few measurement tools have been developed to explore these core competencies. The purpose of this study was to test and validate the nurses' core competence in palliative care (NCPC) instrument. A total of 122 clinical nurse specialists who had completed a postbachelor program in palliative care at two university colleges in Norway answered the questionnaire. The initial analysis, with structural equation modelling, was run in Mplus 7. A modified confirmatory factor analysis revealed the following five domains: knowledge in symptom management, systematic use of the Edmonton symptom assessment system, teamwork skills, interpersonal skills, and life closure skills. The actual instrument needs to be tested in a practice setting with a larger sample to confirm its usefulness. The instrument has the potential to be used to refine clinical competence in palliative care and be used for the training and evaluation of palliative care nurses.

Identification of the need for home visiting nurse: development of a new assessment tool

Objective

To develop a Home Visiting Nursing Service Need Assessment Form (HVNS-NAF) to standardize the decision about the need for home visiting nursing service.

Methods

The sample consisted of older adults who had received coordinated services by care managers. We defined the need for home visiting nursing service by elderly individuals as the decision of the need by a care manager so that the elderly can continue to live independently. Explanatory variables included demographic factors, medical procedure, severity of illness, and caregiver variables. Multiple logistic regression was carried out after univariate analyses to decide the variables to include and the weight of each variable in the HVNS-NAF. We then calculated the sensitivity and specificity of each cutoff value, and defined the score with the highest sensitivity and specificity as the cutoff value.

Results

Nineteen items were included in the final HVNS-NAF. When the cutoff value was 2 points, the sensitivity was 77.0%, specificity 68.5%, and positive predictive value 56.8%.

Conclusions

HVNS-NAF is the first validated standard based on characteristics of elderly clients who required home visiting nursing service. Using the HVNS-NAF may result in reducing the unmet need for home visiting nursing service and preventing hospitalization.

Measuring interpersonal continuity in high-frequency home healthcare services

AIM

To provide a method for assessing the degree of interpersonal continuity adapted to context and to measure and assess the degree of interpersonal continuity for long-term recipients dependent on daily home health care.

BACKGROUND

Interpersonal continuity is important to the quality of care for long-term dependents. In high-frequency home healthcare services where patients receive daily care from many nurses or other health personnel over time, interpersonal continuity may be difficult to attain.

DESIGN

A cross-sectional study with a descriptive design.

METHODS

Information concerning 79 patients receiving long-term frequent care was collected during four weeks in a maximum variation sample of Norwegian municipalities, from January 2009-May 2010. We measured interpersonal continuity objectively using indices of dispersion and the next-day sequence of health personnel. For each measure, we computed the highest feasible level of continuity that could be attained in this home healthcare context given a standard shift plan. This level was then used as benchmark against which the actual level of continuity was assessed.

RESULTS

Patients received on average 51 visits from a mean of 17 different carers during four weeks. The results revealed a low degree of interpersonal continuity in practice, far below what was feasible according to the benchmarks.

CONCLUSION

High-frequency home health care was characterized by interpersonal discontinuity, but with potential for improvement. Objective measures of interpersonal continuity, when the benchmark is adapted to the context, are useful tools for planning and surveying continuity of care.

Family caregiver learning--how family caregivers learn to provide care at the end of life: a qualitative secondary analysis of four datasets

BACKGROUND

Family caregivers are assuming growing responsibilities in providing care to dying family members. Supporting them is fundamental to ensure quality end-of-life care and to buffer potentially negative outcomes, although family caregivers frequently acknowledge a deficiency of information, knowledge, and skills necessary to assume the tasks involved in this care.

AIM

The aim of this inquiry was to explore how family caregivers describe learning to provide care to palliative patients.

DESIGN

Secondary analysis of data from four qualitative studies (n = 156) with family caregivers of dying people.

DATA SOURCES

Data included qualitative interviews with 156 family caregivers of dying people.

RESULTS

Family caregivers learn through the following processes: trial and error, actively seeking needed information and guidance, applying knowledge and skills from previous experience, and reflecting on their current experiences. Caregivers generally preferred and appreciated a supported or guided learning process that involved being shown or told by others, usually learning reactively after a crisis.

CONCLUSIONS

Findings inform areas for future research to identify effective, individualized programs and interventions to support positive learning experiences for family caregivers of dying people.

Co-creating possibilities for patients in palliative care to reach vital goals--a multiple case study of home-care nursing encounters

The patient's home is a common setting for palliative care. This means that we need to understand current palliative care philosophy and how its goals can be realized in home-care nursing encounters (HCNEs) between the nurse, patient and patient's relatives. The existing research on this topic describes both a negative and a positive perspective. There has, however, been a reliance on interview and descriptive methods in this context. The aim of this study was to explore planned HCNEs in palliative care. The design was a multiple case study based on observations. The analysis includes a descriptive and an explanation building phase. The results show that planned palliative HCNEs can be described as a process of co-creating possibilities for the patient to reach vital goals through shared knowledge in a warm and caring atmosphere, based on good caring relations. However, in some HCNEs, co-creation did not occur: Wishes and needs were discouraged or made impossible and vital goals were not reached for the patients or their relatives. Further research is needed to understand why. The co-creative process presented in this article can be seen as a concretization of the palliative care ideal of working with a person-centered approach.

Rural nursing and quality end-of-life care: palliative care ... palliative approach ... or somewhere in-between?

Secondary analysis of data from 2 studies examining palliative care in rural areas was conducted with the aim to better understand how a nursing palliative approach influences quality outcomes at end-of-life. Nurses' ways of being that brought connection and comfort at end-of-life included paying attention to time, privacy, and family support. The rural context with its geography, relationships, and unique resources influenced nurses' abilities to enact a palliative approach. Findings demonstrate that urban-centric models of palliative care do not fit well in rural nursing practice and highlight the importance of understanding the rural context.

Analysis and Proposed Model of Family Caregivers’ Relationships With Home Health Providers and Perceptions of the Quality of Formal Services

Relationships between families and home health nurses promote effective care and service access for those at end of life, positive caregiver experiences, and satisfaction with care. This study explores family caregivers’ accounts of relationships with home care nurses; findings inform a model of relationships and satisfaction with home health services. Ethnographic, qualitative interviews were conducted with 26 bereaved caregivers in one Western Canadian regional health agency. Data analysis was informed by symbolic interactionism. Participants described their relationships with home care nurses and spoke about their assessments of the care provided. Findings highlighted the importance of the length, frequency, and continuity of contact, conversation, socializing, and sharing information. Participants were cognizant of their own and care recipients’ roles in building relationship. Nurse behaviors demonstrating affection, acknowledgment, commitment, and understanding were appreciated. A model links relationship preconditions, relational demonstrations, and perceived care quality and may be used to identify points of intervention.