Dying well: factors that influence the provision of good end-of-life care for older people in acute and long-stay care settings in Ireland

Relationship between staff and quality of care in care homes: StaRQ mixed methods study

Background

Quality of life and care varies between and within the care homes in which almost half a million older people live and over half a million direct care staff (registered nurses and care assistants) work. The reasons are complex, understudied and sometimes oversimplified, but staff and their work are a significant influence.

Objective(s)

To explore variations in the care home nursing and support workforce; how resident and relatives' needs in care homes are linked to care home staffing; how different staffing models impact on care quality, outcomes and costs; how workforce numbers, skill mix and stability meet residents' needs; the contributions of the care home workforce to enhancing quality of care; staff relationships as a platform for implementation by providers.

Design

Mixed-method (QUAL-QUANT) parallel design with five work packages. WP1 - two evidence syntheses (one realist); WP2 - cross-sectional survey of routine staffing and rated quality from care home regulator; WP3 - analysis of longitudinal data from a corporate provider of staffing characteristics and quality indicators, including safety; WP4 - secondary analysis of care home regulator reports; WP5 - social network analysis of networks likely to influence quality innovation. We expressed our synthesised findings as a logic model.

Setting

English care homes, with and without nursing, with various ownership structures, size and location, with varying quality ratings.

Participants

Managers, residents, families and care home staff.

Findings

Staffing's contribution to quality and personalised care requires: managerial and staff stability and consistency; sufficient staff to develop 'familial' relationships between staff and residents, and staff-staff reciprocity, 'knowing' residents, and skills and competence training beyond induction; supported, well-led staff seeing modelled behaviours from supervisors; autonomy to act. Outcome measures that capture the relationship between staffing and quality include: the extent to which resident needs and preferences are met and culturally appropriate; resident and family satisfaction; extent of residents living with purpose; safe care (including clinical outcomes); staff well-being and job satisfaction were important, but underacknowledged.

Limitations

Many of our findings stem from self-reported and routine data with known biases - such as under reporting of adverse incidents; our analysis may reflect these biases. COVID-19 required adapting our original protocol to make it feasible. Consequently, the effects of the pandemic are reflected in our research methods and findings. Our findings are based on data from a single care home operator and so may not be generalised to the wider population of care homes.

Conclusions

Innovative and multiple methods and theory can successfully highlight the nuanced relationship between staffing and quality in care homes. Modifiable characteristics such as visible philosophies of care and high-quality training, reinforced by behavioural and relational role modelling by leaders can make the difference when sufficient amounts of consistent staff are employed. Greater staffing capacity alone is unlikely to enhance quality in a cost-effective manner. Social network analysis can help identify the right people to aid adoption and spread of quality and innovation. Future research should focus on richer, iterative, evaluative testing and development of our logic model using theoretically and empirically defensible - rather than available - inputs and outcomes.

Study registration

This study is registered as PROSPERO CRD42021241066 and Research Registry registration: 1062.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 15/144/29) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 8. See the NIHR Funding and Awards website for further award information.

Enhancing Care of Older Adults Through Standardizing Palliative Care Education

Nursing skill in caring for persons with serious chronic illness is increasingly in demand as the proportion of older adults in the United States increases. There is robust evidence that palliative care education among health care providers influences the reduction of death anxiety and avoidance behavior, while positively impacting self-efficacy and comfort, when caring for persons with serious illness or those nearing death. The international recognition of access to palliative care as a universal human right drives the need for education to adequately prepare nurses who have not been properly prepared for this work. The development of national competencies in palliative care education for nurses is an important step in synthesizing and disseminating available evidence in support of palliative care nursing education. These recently published competencies can lead to policy innovations at local, state, and national levels. Identifying competencies that lead to more clearly defined curricula will ultimately improve standardizing education and improve nursing practice in caring for older adults with serious chronic illness and their families. [Journal of Gerontological Nursing, 49(6), 6-12.].

Dying, death and bereavement: developing a national survey of bereaved relatives

BACKGROUND

Assessing and measuring the experience and quality of care provided is central to the improvement of care delivery of all healthcare systems. This paper reports on the development of a survey instrument to capture the experiences of care at end of life from the perspective of bereaved relatives in the Republic of Ireland.

METHODS

A multi-method, multi-stakeholder, sequential approach was adopted for this study. Items for inclusion in the survey instrument bank were identified through (1) a feasibility study and scoping literature review, (2) expert panel programme board review, (3) focus groups and (4) gap analysis. The following steps were undertaken to prioritise the items for inclusion in the final survey instrument: (1) a Delphi study (2) technical expert panel review (3) cognitive interviews with bereaved relatives and an (4) expert panel programme board review.

RESULTS

Following an iterative process with key stakeholders, a survey instrument was developed with sections focusing on the provision of care at home, in the last nursing home / residential care facility, hospice and hospital, as well as care experience in the last 2 days of life, the relative's experiences of care and support, the circumstances of care surrounding death and demographic information. In total, a bank of 123 questions were prioritised to be included in the National End of Life Survey instrument.

CONCLUSION

The survey will provide a standardised national approach to capturing the experience of care of those who have died, from the perspective of bereaved relatives in the Republic of Ireland. This will allow health service providers, policy makers and regulators to gather important insights into the experiences of care at end of life and will help fulfil the requirement of healthcare services to ensure they are providing high-quality care.

Does context count? The association between quality of care and job characteristics in residential aged care and hospital settings: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

Within residential aged care settings, reduced quality of care (QOC), abuse, and neglect have been global phenomena which require urgent intervention. As the reported rate of these problems is much higher in aged care compared to hospital settings, we investigated whether differing job design characteristics between the two settings might explain the difference.

RESEARCH DESIGN AND METHODS

We used a meta-analysis to compare differences in the relationships between high job demands, low job resources, and job strain with QOC and counter-productive work behaviors (CWBs) across aged care and hospital settings.

RESULTS

Data was extracted from 42 studies (n=55 effects). QOC was negatively correlated with high job demands (ρ̅ =-.22, 95% CI: -.29:-.15, k=7), low job resources (ρ̅ = -.40, 95% CI:-.47:-.32, k=15), and job strain (ρ̅ =-.32, 95% CI: -.38:.-.25, k=22), CWBs had a positive relationship with job demands (ρ̅ =.35, 95%CI: .10:.59, k=3) and job strain (ρ̅ =.34, 95% CI: .13:.56, k=6). The association between poor QOC and low job resources was stronger in aged care (r=-.46, 95% CI:-.55:-36, k=8) than in hospital settings (r= -.30, 95% CI:-.41:-.18, k=7).

DISCUSSION AND IMPLICATIONS

Our findings suggest that relationships between low job resources and poor quality of care are exacerbated in residential aged care contexts. To improve care outcomes, stakeholders should improve job resources such as skill discretion, supervisory supports, and increased training and staffing levels in residential aged care.

Quality of Life among Next of Kin of Frail Older People in Nursing Homes: An Interview Study after an Educational Intervention concerning Palliative Care

One cornerstone of palliative care is improving the family’s quality of life (QoL). The principles of palliative care have not been sufficiently applied in nursing homes. The aim of this study was to investigate the experiences of QoL of next of kin of frail older persons in nursing homes after an educational intervention concerning palliative care. This qualitative interview study with 37 next of kin used an abductive design with deductive and inductive content analysis. The deductive analysis confirmed the three themes of QoL from the study before the implementation: (1) orientation to the new life-situation, (2) challenges in the relationship, and (3) the significance of the quality of care in the nursing home. The inductive analysis resulted in the sub-theme “Unspoken palliative care”. Being the next of kin of an older person living in a nursing home can be distressing despite round-the-clock care, so staff need to apply a more explicitly palliative care perspective. Future research needs to evaluate the influence of meaning-focused coping on next of kin’s QoL and integrate this knowledge in psychosocial interventions. Clinical Trial Database for Clinical Research: KUPA project NCT02708498.

The perspective of professional caregivers working in generalist palliative care on 'good dying': An integrative review

In today's industrial societies, many people die receiving professional care. Although specialist palliative and hospice care have often been identified as ideal care approaches to promote good dying, more people die receiving generalist palliative care. This integrative review examines how professional caregivers providing generalist palliative care in hospitals, nursing or private homes define good dying. Furthermore, through comparative analysis of existing empirical studies, it explores conceptual aspects in researching good dying that better reflect the social complexity of this phenomenon. Three databases (Scopus, MEDLINE, and CINAHL) were searched for peer-reviewed studies published between January 2000 and April 2020. Studies were selected if they presented original empirical findings from qualitative or quantitative studies on the perspective of professional caregivers in generalist palliative care (nurses, physicians, surgeons, clergy, and other staff) on good dying or related concepts (e.g., good death, dignity in dying, or quality of life at the end of life). 42 studies were included in the review. They identified good dying as expected, accepted and prepared dying, as free from pain and suffering, as socially embedded, as being at peace with one's life and situation, as supported with individualised and holistic care, as based upon professional cooperation and communication, and as in a peaceful and private environment. The paper concludes that the perspective of professional caregivers in generalist palliative care shares many elements of good dying with societal and specialist palliative care discourses around good dying. Through comparing the different studies, the review found that studies that explicated who benefitted from ideals and practices of good dying, questioned the dichotomous categorisation of good/bad dying, or discussed the compatibility of elements of good dying, provided more nuanced perspectives on this topic. Thus, the review calls for a more systematic analysis of these aspects in research of good dying.

Experiences of surgical nurses in providing end-of-life care in an acute care setting: a qualitative study

BACKGROUND

The number of deaths occurring in hospitals is rising, and many occur in settings other than specialist palliative care, oncology or critical care. Nurses working outside these specialist environments report end-of-life (EoL) care as a source of stress. This research aimed to explore these experiences.

AIMS AND METHODS

This qualitative study, using semi-structured interviews as a research technique, aimed to investigate the experiences of surgical nurses caring for dying patients.

RESULTS

Five themes emerged: understanding of and preference for EoL care; perceived barriers while providing EoL care; robust support from the team as a facilitator while providing EoL care; symptom management; future training and support.

CONCLUSION

Participants considered providing EoL care as part of their professional role and reported that they were able to provide appropriate physical care. Participants identified challenges in providing emotional and psychological support to dying patients and their families in an acute surgical setting.

Living, loving and letting go-navigating the relational within palliative care of older people in long-term care facilities: An action research study

BACKGROUND

Long term care facilities are important environments for the delivery of palliative care, which includes end of life care. Despite this, staff may feel this care focus is separate to their roles. Consequently, this study explores and makes visible how palliative care is understood in long term residential care facilities for older people. It focuses on how relationships with residents and families are experienced by nurses and health care assistants and how this influences the introduction and provision of palliative care to older people in long term care facilities.

OBJECTIVES

To develop an understanding of what palliative care means to staff caring for older people in residential care.

METHODS

A co-operative inquiry action research approach was used. A total of 18 healthcare assistants and 16 registered nurses in two older person long term care facilities participated in co-operative inquiry groups. Co-inquirers reflected on deaths that occurred over a 6-month period and generated narratives on their relationships in the context of palliative care.

RESULTS

Three themes were identified to describe relationships which were immersed in an ethos of person-centred care. These were living, loving and letting go. Living rather than dying was the predominant focus of care. Loving described deep engagement with older people and families while letting go navigated the dying process.

CONCLUSIONS

Staff in nursing homes experience deep attachments to residents when delivering palliative care and end of life care. There is a need to understand these relationships and how they impact on the understanding and integration of palliative care in older person residential care as well as acknowledging and addressing staff's grief processes to enhance resilience.

Understanding the staff behaviours that promote quality for older people living in long term care facilities: A realist review

BACKGROUND

Little is known about how the workforce influences quality in long term care facilities for older people. Staff numbers are important but do not fully explain this relationship.

OBJECTIVES

To develop theoretical explanations for the relationship between long-term care facility staffing and quality of care as experienced by residents.

DESIGN

A realist evidence synthesis to understand staff behaviours that promote quality of care for older people living in long-term care facilities.

SETTING

Long-term residential care facilities PARTICIPANTS: Long-term care facility staff, residents, and relatives METHODS: The realist review, (i) was co-developed with stakeholders to determine initial programme theories, (ii) systematically searched the evidence to test and develop theoretical propositions, and (iii) validated and refined emergent theory with stakeholder groups.

RESULTS

66 research papers were included in the review. Three key findings explain the relationship between staffing and quality: (i) quality is influenced by staff behaviours; (ii) behaviours are contingent on relationships nurtured by long-term care facility environment and culture; and (iii) leadership has an important influence on how organisational resources (sufficient staff effectively deployed, with the knowledge, expertise and skills required to meet residents' needs) are used to generate and sustain quality-promoting relationships. Six theoretical propositions explain these findings.

CONCLUSION

Leaders (at all levels) through their role-modelling behaviours can use organisational resources to endorse and encourage relationships (at all levels) between staff, residents, co-workers and family (relationship centred care) that constitute learning opportunities for staff, and encourage quality as experienced by residents and families.

Healthcare providers' views and experiences of non-specialist palliative care in hospitals: A qualitative systematic review and thematic synthesis

BACKGROUND

Healthcare providers working in hospitals are frequently exposed to patients with palliative care needs. For most patients, these reflect non-specialist rather than specialist palliative care needs. Embedding palliative care principles early in patients' disease trajectories within acute care delivery in hospitals, however, is a challenge. How to best understand the experiences of those providing non-specialist palliative care in hospitals has not been systematically assessed.

AIM

To synthesise the evidence on healthcare providers' views and experiences of non-specialist palliative care in hospitals.

DESIGN

A qualitative systematic review and thematic synthesis using Thomas and Harden's thematic synthesis framework.

DATA SOURCES

Databases of MEDLINE, CINAHL, PsycINFO and EMBASE were searched from date of inception to March 2018. Studies were eligible for inclusion if they reported on healthcare providers' views and experiences of non-specialist palliative care in hospitals. Studies were appraised for quality but not excluded on that basis. The review was prospectively registered with the International Prospective Register of Systematic Reviews.

RESULTS

Thirty-nine papers of 37 studies were included, representing 985 hospital healthcare providers' views and experiences. Four major analytical themes emerged; 'Understanding of Palliative Care', 'Complexities of Communication', 'Hospital Ecosystem' and 'Doctors and Nurses - a Different Lens'.

CONCLUSIONS

Non-specialist palliative care in hospitals is operationalised as care in the last weeks and days of life. The organisation of acute care, inter-disciplinary working practices, clinician attitudes, poor communication structures and lack of education and training in palliative care principles exacerbates poor implementation of this care earlier for patients in hospitals.

Dying in acute hospitals: voices of bereaved relatives

Background

Internationally there is an increasing concern about the quality of end-of-life care (EoLC) provided in acute hospitals. More people are cared for at end of life and die in acute hospitals than in any other healthcare setting. This paper reports the views of bereaved relatives on the experience of care they and the person that died received during their last admission in two university adult acute tertiary hospitals.

Methods

Relatives of patients who died were invited to participate in a post-bereavement postal survey. An adapted version of VOICES (Views of Informal Carers - Evaluation of Services) questionnaire was used. VOICES MaJam has 36 closed questions and four open-ended questions. Data were gathered in three waves and analysed using SPSS and NVivo. 356 respondents completed the survey (46% response rate).

Results

The majority of respondents (87%: n = 303) rated the quality of care as outstanding, excellent or good during the last admission to hospital. The quality of care by nurses, doctors and other staff was highly rated. Overall, care needs were well met; however, findings identified areas of care which could be improved, including communication and the provision of emotional and spiritual support. In addition, relatives strongly endorsed the provision of EoLC in single occupancy rooms, the availability of family rooms on acute hospital wards and the provision of bereavement support.

Conclusions

This research provides a powerful snapshot in time into what works well and what could be improved in EoLC in acute hospitals. Findings are reported under several themes, including the overall quality of care, meeting care needs, communication, the hospital environment and support for relatives. Results indicate that improvements can be made that build on existing good practice that will enhance the experience of care for dying persons and their relatives. The study adds insights in relation to relative’s priorities for EoLC in acute hospitals and can advance care providers’, policy makers’ and educationalists’ priorities for service improvement.

Evaluation of person-centeredness in nursing homes after a palliative care intervention: pre- and post-test experimental design

BACKGROUND

The needs of care based on palliative principles are stressed for all people with progressive and/or life-limiting conditions, regardless of age and the place in which care is provided. Person-centred palliative care strives to make the whole person visible and prioritizes the satisfaction of spiritual, existential, social, and psychological needs to the same extent as physical needs. However, person-centred palliative care for older persons in nursing homes seems to be sparse, possibly because staff in nursing homes do not have sufficient knowledge, skills, and training in managing symptoms and other aspects of palliative care.

METHODS

This study aimed to evaluate whether an educational intervention had any effect on the staff's perception of providing person-centred palliative care for older persons in nursing homes.

METHODS

A knowledge-based palliative care intervention consisting of five 2-h seminars during a 6-month period was implemented at 20 nursing homes in Sweden. In total, 365 staff members were participated, 167 in the intervention group and 198 in the control group. Data were collected using two questionnaires, the Person-centred Care Assessment Tool (P-CAT) and the Person-Centred Climate Questionnaire (PCQ-S), answered before (baseline) and 3 months after (follow-up) the educational intervention was completed. Descriptive, comparative, and univariate logistical regression analyses were performed.

RESULTS

Both the intervention group and the control group revealed high median scores in all subscales at baseline, except for the subscale amount of organizational and environmental support in the P-CAT. The staff's high rating level of person-centred care before the intervention provides limited space for further improvements at follow-up.

CONCLUSION

This study shows that staff perceived that managers' and the organization's amount of support to them in their everyday work was the only area for improvement in order to maintain person-centred care. The experiences among staff are crucial knowledge in understanding how palliative care can be made person-centred in spite of often limited resources in nursing homes. The dose and intensity of education activities of the intervention model need to be tested in future research to develop the most effective implementation model.

TRIAL REGISTRATION

NCT02708498 . Date of registration 26 February 2016.

Conversations about Death and Dying with Older People: An Ethnographic Study in Nursing Homes

Nursing homes are often places where older persons “come to die.” Despite this, death and dying are seldom articulated or talked about. The aim of this study was to explore assistant nurses’ experiences of conversations about death and dying with nursing home residents. This study is part of an implementation project through a knowledge-based educational intervention based on palliative care principles. An ethnographic study design was applied in seven nursing homes, where eight assistant nurses were interviewed and followed in their daily assignments through participant observations. The assistant nurses stated that they had the knowledge and tools to conduct such conversations, even though they lacked the time and felt that emotional strain could be a hinder for conversations about death and dying. The assistant nurses used the strategies of distracting, comforting, and disregarding either when they perceived that residents’ reflections on death and dying were part of their illness and disease or when there was a lack of alignment between the residents’ contemplations and the concept of dying well. They indicated that ambivalence and ambiguity toward conversations about death and dying should be taken into consideration in future implementations of knowledge-based palliative care that take place in nursing homes after this project is finalized.

Towards evidence-based palliative care in nursing homes in Sweden: a qualitative study informed by the organizational readiness to change theory

BACKGROUND

Sweden has a policy of supporting older people to live a normal life at home for as long as possible. Therefore, it is often the oldest, most frail people who move into nursing homes. Nursing home staff are expected to meet the existential needs of the residents, yet conversations about death and dying tend to cause emotional strain. This study explores organizational readiness to implement palliative care based on evidence-based guidelines in nursing homes in Sweden. The aim was to identify barriers and facilitators to implementing evidence-based palliative care in nursing homes.

METHODS

Interviews were carried out with 20 managers from 20 nursing homes in two municipalities who had participated along with staff members in seminars aimed at conveying knowledge and skills of relevance for providing evidence-based palliative care. Two managers responsible for all elderly care in each municipality were also interviewed. The questions were informed by the theory of Organizational Readiness for Change (ORC). ORC was also used as a framework to analyze the data by means of categorizing barriers and facilitators for implementing evidence-based palliative care.

RESULTS

Analysis of the data yielded ten factors (i.e., sub-categories) acting as facilitators and/or barriers. Four factors constituted barriers: the staff's beliefs in their capabilities to face dying residents, their attitudes to changes at work as well as the resources and time required. Five factors functioned as either facilitators or barriers because there was considerable variation with regard to the staff's competence and confidence, motivation, and attitudes to work in general, as well as the managers' plans and decisional latitude concerning efforts to develop evidence-based palliative care. Leadership was a facilitator to implementing evidence-based palliative care.

CONCLUSIONS

There is a limited organizational readiness to develop evidence-based palliative care as a result of variation in the nursing home staff's change efficacy and change commitment as well as restrictions in many contextual conditions. There are considerable individual- and organizational-level challenges to achieving evidence-based palliative care in this setting. The educational intervention represents one of many steps towards developing a culture conducive to evidence-based nursing home palliative care.

'Powerlessness' or 'doing the right thing' - Moral distress among nursing home staff caring for residents at the end of life: An interpretive descriptive study

BACKGROUND

Caring for dying people can contribute to moral distress experienced by healthcare professionals. Moral distress can occur when this caring is restricted by organisational processes, resources or the provision of futile care. These factors apply to end of life care in nursing homes but research is lacking.

AIM

To describe how nursing home staff experience moral distress when caring for residents during and at the end of life.

METHODS

An interpretive descriptive design, using the critical incident technique in semi-structured interviews to collect data from nursing home staff. Data were analysed using a thematic analysis approach.

SETTING

Four nursing homes in one large metropolitan area.

PARTICIPANTS

A total of 16 staff: 2 nurse managers, 4 nurses and 10 care assistants.

FINDINGS

Participants described holding 'good dying' values which influenced their practice. The four practice-orientated themes of advocating, caring, communicating and relating with residents were found to influence interactions with residents, relatives, general practitioners, and colleagues. These led staff to be able to 'do the right thing' or to experience 'powerlessness', which could in turn lead to staff perceiving a 'bad death' for residents.

CONCLUSION

When there are incongruent values concerning care between staff and others involved in the care of residents, staff feel powerless to 'do the right thing' and unable to influence care decisions in order to avoid a 'bad death'. This powerlessness is the nature of their moral distress.

Advance care planning for nursing home residents with dementia: Influence of 'we DECide' on policy and practice

OBJECTIVES

(1) To pilot 'we DECide' in terms of influence on advance care planning policy and practice in nursing home dementia care units. (2) To investigate barriers and facilitators for implementing 'we DECide'.

METHODS

This was a pre-test-post-test study in 18 nursing homes. Measurements included: compliance with best practice of advance care planning policy (ACP-audit); advance care planning practice (ACP criteria: degree to which advance care planning was discussed, and OPTION scale: degree of involvement of residents and families in conversations).

RESULTS

Advance care planning policy was significantly more compliant with best practice after 'we DECide'; policy in the control group was not. Advance care planning was not discussed more frequently, nor were residents and families involved to a higher degree in conversations after 'we DECide'. Barriers to realizing advance care planning included staff's limited responsibilities; facilitators included support by management staff, and involvement of the whole organization.

CONCLUSION

'We DECide' had a positive influence on advance care planning policy. Daily practice, however, did not change. Future studies should pay more attention to long-term implementation strategies.

PRACTICE IMPLICATIONS

Long-term implementation of advance care planning requires involvement of the whole organization and a continuing support system for health care professionals.

What's the diagnosis? Organisational culture and palliative care delivery in residential aged care in New Zealand

Organisational culture has been shown to impact on resident outcomes in residential aged care (RAC). This is particularly important given the growing number of residents with high palliative care needs. The study described herein (conducted from January 2013 to March 2014) examined survey results from a convenience sample of 46 managers, alongside interviews with a purposively selected sample of 23 bereaved family members in order to explore the perceptions of organisational culture within New Zealand RAC facilities in one large urban District Health Board. Results of the Organisational Culture Assessment Instrument (OCAI) completed by managers indicated a preference for a 'Clan' and the structured 'Hierarchy' culture. Bereaved family interviews emphasised both positive and negative aspects of communication, leadership and teamwork, and relationship with residents. Study results from both managers' OCAI survey scores and next of kin interviews indicate that while the RAC facilities are culturally oriented towards providing quality care for residents, they may face barriers to adopting organisational processes supportive of this goal.

Context, mechanisms and outcomes in end of life care for people with advanced dementia

Background

The majority of people with dementia in the UK die in care homes. The quality of end of life care in these environments is often suboptimal. The aim of the present study was to explore the context, mechanisms and outcomes for providing good palliative care to people with advanced dementia residing in UK care homes from the perspective of health and social care providers.

Method

The design of the study was qualitative which involved purposive sampling of health care professionals to undertake interactive interviews within a realist framework. Interviews were completed between September 2012 and October 2013 and were thematically analysed and then conceptualised according to context, mechanisms and outcomes. The settings were private care homes and services provided by the National Health Service including memory clinics, mental health and commissioning services in London, United Kingdom. The participants included 14 health and social care professionals including health care assistants, care home managers, commissioners for older adults’ services and nursing staff.

Results

Good palliative care for people with advanced dementia is underpinned by the prioritisation of psychosocial and spiritual care, developing relationships with family carers, addressing physical needs including symptom management and continuous, integrated care provided by a multidisciplinary team. Contextual factors that detract from good end of life care included: an emphasis on financial efficiency over person-centred care; a complex health and social care system, societal and family attitudes towards staff; staff training and experience, governance and bureaucratisation; complexity of dementia; advance care planning and staff characteristics. Mechanisms that influence the quality of end of life care include: level of health care professionals’ confidence, family uncertainty about end of life care, resources for improving end of life care and supporting families, and uncertainty about whether dementia specific palliative care is required.

Conclusions

Contextual factors regarding the care home environment may be obdurate and tend to negatively impact on the quality of end of life dementia care. Local level mechanisms may be more amenable to improvement. However, systemic changes to the care home environment are necessary to promote consistent, equitable and sustainable high quality end of life dementia care across the UK care home sector.

Nurses respond to patients' psychosocial needs by dealing, ducking, diverting and deferring: an observational study of a hospice ward

BACKGROUND

Psychosocial support is considered a central component of nursing care but it remains unclear as to exactly how this is implemented in practice. The aim of this study was to provide a descriptive exploration of how psychosocial needs (PNs) of patients in a hospice ward are expressed and met, in order to develop an understanding of the provision of psychosocial support in practice.

METHODS

An embedded mixed-methods study was conducted in one hospice ward. Data collection included observations of patients' expressions of PNs and nurses' responses to those expressed PNs, shift hand-overs and multi-disciplinary meetings. Interviews about the observed care were conducted with the patients and nurses and nursing documentation pertaining to psychosocial care was collated. Descriptive statistical techniques were applied to quantitative data in order to explore and support the qualitative observational, interview and documentary data.

RESULTS

During the 8-month period of observation, 227 encounters within 38 episodes of care were observed among 38 nurses and 47 patients. Within these encounters, 330 PNs were expressed. Nurses were observed immediately responding to expressed PNs in one of four ways: dealing (44.2 %), deferring (14.8 %), diverting (10.3 %) and ducking (30.7 %). However, it is rare that one type of PN was clearly expressed on its own: many were expressed at the same time and usually while the patient was interacting with the nurse for another reason, thus making the provision of psychosocial support challenging. The nurses' response patterns varied little according to type of need.

CONCLUSIONS

The provision of psychosocial support is very complex and PNs are not always easily recognised. This study has allowed an exploration of the actual PNs of patients in a hospice setting, the way in which they were expressed, and how nurses responded to them. The nurses faced the challenge of responding to PNs whilst carrying out the other duties of their shift, and the fact that nurses can provide psychosocial support as an inherent component of practice was verified. The data included in this paper, and the discussions around the observed care, provides nurses everywhere with an example against which to compare their own practice.

A mobile hospice nurse teaching team's experience: training care workers in spiritual and existential care for the dying - a qualitative study

Background

Nursing home and home care nursing staff must increasingly deal with palliative care challenges, due to cost cutting in specialized health care. Research indicates that a significant number of dying patients long for adequate spiritual and existential care. Several studies show that this is often a source of anxiety for care workers. Teaching care workers to alleviate dying patients’ spiritual and existential suffering is therefore important. The aim of this study is to illuminate a pioneering Norwegian mobile hospice nurse teaching team’s experience with teaching and training care workers in spiritual and existential care for the dying in nursing homes and home care settings.

Methods

The team of expert hospice nurses participated in a focus group interview. Data were analyzed using a phenomenological hermeneutical method.

Results

The mobile teaching team taught care workers to identify spiritual and existential suffering, initiate existential and spiritual conversations and convey consolation through active presencing and silence. The team members transferred their personal spiritual and existential care knowledge through situated “bedside teaching” and reflective dialogues. “The mobile teaching team perceived that the care workers benefitted from the situated teaching because they observed that care workers became more courageous in addressing dying patients’ spiritual and existential suffering.

Discussion

Educational research supports these results. Studies show that efficient workplace teaching schemes allowexpert practitioners to teach staff to integrate several different knowledge forms and skills, applying a holisticknowledge approach. One of the features of workplace learning is that expert nurses are able to guide novices through the complexities of practice. Situated learning is therefore central for becoming proficient.

Conclusions

Situated bedside teaching provided by expert mobile hospice nurses may be an efficient way to develop care workers’ courage and competency to provide spiritual and existential end-of-life-care. Further research is recommended on the use of mobile expert nurse teaching teams to improve nursing competency in the primary health care sector.

Learning, support and communication for staff in care homes: outcomes of reflective debriefing groups in two care homes to enhance end-of-life care

BACKGROUND

Nursing care homes are increasingly the place where frail older people die. However, training in end-of-life care is not statutory.

AIMS AND OBJECTIVES

To develop strategies to promote quality end-of-life care in nursing care homes.

DESIGN

Action research was used to work collaboratively with the managers and staff in two nursing care homes to develop end-of-life care.

METHODS

There were three overarching phases: an exploratory phase, feedback/planning of actions and a summative evaluation. Two main actions were inductively derived. One of the actions, reflective debriefing groups following a resident's death, is reported.

RESULTS

Ten reflective debriefing groups, led by the researcher (a specialist palliative care nurse), were undertaken. The groups facilitated learning at three different levels (being taught, developing understanding and critical thinking) and enabled staff to feel supported and valued.

IMPLICATIONS FOR PRACTICE

The use of reflective debriefing groups is a useful mechanism to support experience-based learning about death/dying in care homes.

Meaning-Making and Managing Difficult Feelings: Providing Front-Line End-of-Life Care

Managing grief and difficult emotions related to end-of-life (EOL) care is an often under-recognized part of the work of resident care aides (RCAs). In this interpretive analysis we explore the shared and socially constructed ideas that 11 RCAs in 1 Canadian city employ to make sense of death and the provision of EOL care. RCAs spoke of personal challenges involved in witnessing death and experiencing loss, as well as helplessness and frustration when they could not provide quality EOL care. RCAs invoked “consoling refrains” to manage grief, including “such is life,” “they are better off,” and “they had a full life.” To manage guilt and moral distress, RCAs reminded themselves “I did my best” and “I experience rewards.” Though these ideas help RCAs, some may need to be reframed through coaching and mentorship, to prevent unintended negative effects on care or the reproduction of ageist beliefs more broadly.

"A room full of chairs around his bed": being present at the death of a loved one in Veterans Affairs Medical Centers

Historically, death took place at home where family held vigil around the dying patient. Today, family presence is an important feature of death and dying in hospital settings. We used hermeneutic phenomenology to explore experiences of being present at the hospital death of a loved one. We conducted in-depth, face-to-face interviews with 78 recently bereaved next-of-kin of veterans who died in 6 Veterans Affairs (VA) Medical Centers in the Southeast United States. Two major themes emerged: 1) "settling in," characteristic of the experiences of wives and daughters in the initial phase of the patient's hospitalization; and 2) "gathering around," characteristic of the experiences of a wider array of family members as the patient neared death. An in-depth understanding of experiences of next-of-kin present at the hospital death of a loved one can increase staff awareness of family's needs and empower staff to develop policies and procedures for supporting family members.

The Liverpool Care Pathway: does it improve quality of dying? [corrected]

The Liverpool Care Pathway (LCP) for the dying patient is an integrated care pathway that was developed to assist non-specialist palliative care staff care for dying patients in acute clinical areas. The LCP has generated numerous debates among health professionals regarding its strengths and weaknesses. The complexity of patient needs at the end-of-life cannot be underestimated and the LCP provides the foundations of quality evidence-based care patients require, particularly in the final phase of dying. Nevertheless, not all health professionals are in agreement as to the advantages of using integrated care pathways in clinical practice. Despite the attention that has surrounded the LCP there is limited evidence to suggest that it improves end-of-life care. This article examines the evidence in relation to the LCP as a tool to improve palliative care for dying patients and their families in non-specialized palliative care practice.