Legitimising and rationalising in talk about satisfaction with formal healthcare among bereaved family members

Perceptions of bereaved family members of nursing care on an inpatient hospice palliative care unit

BACKGROUND

Understanding family members' (FMs) perceptions of the care provided by nurses is crucial to facilitating positive outcomes for FMs.

AIMS

To better understand how bereaved FMs perceive the care nurses provide in an inpatient hospice palliative care unit.

METHODS

An exploratory study was conducted, with an interpretive description methodology. It was guided by the question: 'How do bereaved FMs perceive nursing care in our unit, and how does this influence their bereavement experiences?' A total of 10 FMs-or close friends-who had a significant other die on a palliative care unit were interviewed.

FINDINGS

Findings support the belief that positive relationships and interactions with nurses impact families' perceptions of end of life. Nurses create a therapeutic environment, building a sense of ease and meaning for patients and families.

CONCLUSION

Participation of nurses in rituals and patient-honouring practices after death may help families to cope and create positive memories during their grieving process.

Unsolved problems and unwanted decision-making in the last year of life: A qualitative analysis of comments from bereaved caregivers

OBJECTIVES

Patients in their last year of life, as well as their relatives, often feel that existent care structures of the healthcare system do not adequately address their individual needs and challenges. This study analyzes unmet needs in terms of unsolved problems and unwanted decision-making in the health and social care of patients in their last year of life from the perspective of bereaved caregivers.

METHODS

This qualitative study is based on free-text comments from informal caregivers of deceased patients collected as part of the Last-Year-of-Life-Study-Cologne (LYOL-C) using a postal survey. With qualitative content analysis, a category system with main and subcategories was developed in a multi-step process.

RESULTS

Free-text commentaries and demographic data were collected from 240 bereaved caregivers. Particularly outside of hospice and palliative care services, study participants addressed the following unsolved problems: poor communication with medical and nursing staff, insufficient professional support for informal caregivers, inadequate psycho-social support for patients, and poor management of pain and other symptoms. Respondents often stated that their relative had to be cared for and die outside their own home, which the relative did not want.

SIGNIFICANCE OF RESULTS

Our findings suggest the necessity for greater awareness of patients' and their relatives' needs in the last year of life. Addressing individual needs, integrating palliative and hospice care in acute hospitals and other healthcare structures, and identifying patients in their last year of life and their caregivers could help to achieve more targeted interventions and optimization of care.

Conversations on Cancer Chemotherapy Cessation in Patients With Advanced Cancer: Qualitative Findings From a Multi-Institutional Study

PURPOSE

As many as 20% of oncology patients receive chemotherapy in the last 14 days of their lives. This study characterized conversations between patients and cancer clinicians on chemotherapy cessation in the setting of advanced cancer.

METHODS

This 3-site study captured real-time, audio-recorded interviews between oncology clinicians and patients with cancer during actual clinic visits. Audio-recordings were reviewed for discussion of chemotherapy cessation and were analyzed qualitatively.

RESULTS

Among 525 recordings, 14 focused on stopping chemotherapy; 14 patients participated with 11 different clinicians. Two types of nonmutually exclusive conversation elements emerged: direct and specific elements that described an absence of effective therapeutic options and indirect elements. An example of a direct element is as follows: "…You know this is…always really tough…But I-I think that you may need more help…I think we're close to stopping chemotherapy…And hospice is really helpful to have in place…" In contrast, the second conversation element was more convoluted: "…transplant is not an option and surgery is not an option…The options…are taking a pill…It doesn't shrink the tumor…It may help you live a little longer. But I'm worried if [you] had the pill, it's still a therapy and it still has side effects. I [am] worried if I give it to you now, that you're so weak, it will make you worse." No relationship seemed apparent between conversation elements and chemotherapy cessation.

CONCLUSIONS

Conversations on chemotherapy cessation are complex; multiple factors appear to drive the decision to stop.

'If there were doctors who could understand our problems, I would already be better': dissatisfactory health care and marginalisation in superdiverse neighbourhoods

How people in community settings describe their experience of disappointing health care, and their responses to such dissatisfaction, sheds light on the role of marginalisation and underlines the need for radically responsive service provision. Making the case for studying unprompted accounts of dissatisfaction with healthcare provision, this is an original analysis of 71 semi-structured interviews with healthcare users in superdiverse neighbourhoods in four European cities. Healthcare users spontaneously express disappointment with services that dismiss their concerns and fail to attend to their priorities. Analysing characteristics of these healthcare users show that no single aspect of marginalisation shapes the expression of disappointment. In response to disappointing health care, users sought out alternative services and to persuade reluctant service providers, and they withdrew from services, in order to access more suitable health care and to achieve personal vindication. Promoting normative quality standards for diverse and diversifying populations that access care from a range of public and private service providers is in tension with prioritising services that are responsive to individual priorities. Without an effort towards radically responsive service provision, the ideal of universal access on the basis of need gives way to normative service provision.

Applying the concept of structural empowerment to interactions between families and home-care nurses

Interpretations of family carer empowerment in much nursing research, and in home-care practice and policy, rarely attend explicitly to families' choice or control about the nature, extent or length of their involvement, or control over the impact on their own health. In this article, structural empowerment is used as an analytic lens to examine home-care nurses' interactions with families in one Western Canadian region. Data were collected from 75 hrs of fieldwork in 59 interactions (18 nurses visiting 16 families) and interviews with 12 nurses and 11 family carers. Generally, nurses prioritized client empowerment, and their practice with families appeared oriented to supporting their role and needs as carers (i.e. rather than as unique individuals beyond the caring role), and reinforcing the caring role through validation and recognition. Although families generally expressed appreciation for these interactions, a structural empowerment lens illustrates how the broad context of home care shapes the interpretation and practice of empowerment in ways that can, paradoxically, be disempowering for families. Opportunities to effectively support family choice and control when a client is being cared for at home are discussed.

Bereaved family members' perceptions of the quality of end-of-life care across four types of inpatient care settings

BACKGROUND

The aims of this study were to gain a better understanding of how bereaved family members perceive the quality of EOL care by comparing their satisfaction with quality of end-of-life care across four different settings and by additionally examining the extent to which demographic characteristics and psychological variables (resilience, optimism, grief) explain variation in satisfaction.

METHODS

A cross-sectional mail-out survey was conducted of bereaved family members of patients who had died in extended care units (n = 63), intensive care units (n = 30), medical care units (n = 140) and palliative care units (n = 155). 1254 death records were screened and 712 bereaved family caregivers were identified as eligible, of which 558 (who were initially contacted by mail and then followed up by phone) agreed to receive a questionnaire and 388 returned a completed questionnaire (response rate of 70%). Measures included satisfaction with end-of-life care (CANHELP- Canadian Health Care Evaluation Project - family caregiver bereavement version; scores range from 0 = not at all satisfied to 5 = completely satisfied), grief (Texas Revised Inventory of Grief (TRIG)), optimism (Life Orientation Test - Revised) and resilience (The Resilience Scale). ANCOVA and multivariate linear regression were used to analyze the data.

RESULTS

Family members experienced significantly lower satisfaction in MCU (mean = 3.69) relative to other settings (means of 3.90 [MCU], 4.14 [ICU], and 4.00 [PCU]; F (3371) = 8.30, p = .000). Statistically significant differences were also observed for CANHELP subscales of "doctor and nurse care", "illness management", "health services" and "communication". The regression model explained 18.9% of the variance in the CANHELP total scale, and between 11.8% and 27.8% of the variance in the subscales. Explained variance in the CANHELP total score was attributable to the setting of care and psychological characteristics of family members (44%), in particular resilience.

CONCLUSION

Findings suggest room for improvement across all settings of care, but improving quality in acute care and palliative care should be a priority. Resiliency appears to be an important psychological characteristic in influencing how family members appraise care quality and point to possible sites for targeted intervention.

'You only have one chance to get it right': A qualitative study of relatives' experiences of caring at home for a family member with terminal cancer

BACKGROUND

Relatives looking after a terminally ill family member at home face numerous challenges. Studies into relatives' experiences of home caregiving have been criticised for their descriptive nature and lack of theoretical underpinnings.

AIM

To explore the emotional challenges faced by home caregivers, and their experiences of healthcare professionals, from the perspective of existential psychology.

DESIGN

A qualitative study using semi-structured interviews. Transcripts were analysed thematically using the Framework approach.

SETTING/PARTICIPANTS

The study took place within an inner-city London hospice. Participants (n = 15) were recently bereaved adult relatives of cancer patients who cared for their family member at home.

RESULTS

Participants' experiences of being a caregiver and of professional support were highly varied. The analysis generated 15 themes which were organised into a framework based on Yalom's four 'existential conditions': responsibility (e.g. 'being the linchpin of care'; 'you only have one chance to get it right'), isolation (e.g. 'being on my own', 'being held in mind'), death (e.g. 'knowing but not knowing') and meaningfulness (e.g. 'giving something back', 'acceptance and gratitude'). Healthcare professionals were perceived as influential in both helping and hindering relatives in meeting the challenges they faced.

CONCLUSION

Existential psychology provides a theoretical perspective from which to understand the psychological complexity of the emotional challenges home caregivers face and a framework which may usefully inform research and clinical practice. Professionals' attentiveness to caregivers' needs can have powerful effects in assuaging anxiety, reducing isolation and enabling relatives to connect with the meaningfulness of caregiving.

What family caregivers learn when providing care at the end of life: a qualitative secondary analysis of multiple datasets

OBJECTIVE

Although growing numbers of family members provide end-of-life care for dying persons, caregivers frequently report lacking essential information, knowledge, and skills. This analysis explicates what family members learn during the process of providing end-of-life care.

METHOD

Four qualitative interview studies of family caregivers to those at the end of life (n = 156) formed the basis of a secondary data analysis.

RESULTS

Thematic and cross-comparative analyses found three general kinds of learning that were described-knowledge about: (1) the situation and the illness (including what to expect), (2) how to provide care, and (3) how to access help. Learning gaps, preferences, and potential inequities were identified. Further, in some instances, participant talk about "learning" appears to reflect a meaning-making process that helps them accept their situation, as suggested by the phrase "I have had to learn."

SIGNIFICANCE OF RESULTS

Findings can inform the development of individualized educational programs and interventions for family caregivers.

Improving end-of-life care in hospitals: a qualitative analysis of bereaved families' experiences and suggestions

OBJECTIVES

To explore and document the experiences and expectancies of bereaved family members concerning the end-of-life (EOL) care of their deceased relative in a general hospital setting.

METHODS

Cross-sectional study using a questionnaire that included open-ended questions. Free-text answers were evaluated with qualitative content analysis. A total of 270 family members provided information about improvements in inpatient care.

RESULTS

Families described structural deficiencies. Furthermore, they requested a more holistic patient health care beyond medical treatment and expressed the wish for more professional support for families.

DISCUSSION

The view of bereaved families confirmed the need for improvement in general hospital EOL care. The results underline the importance of a more holistic EOL care. The application of communication skills training, structured family meetings, and integrated pathways is recommended.

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.