A qualitative study of nurses' perspective about the impact of end-of-life communication on the goal of end-of-life care in nursing home

A conceptual model of the nurse's role as primary palliative care provider in goals of care communication

Objective

Nurses have opportunities to engage in goals of care conversations that can promote palliative care communication. The purpose of this study was to describe nurses' experiences in goals of care communication as summarized in the literature and to present a conceptual model of communication pathways for nurses.

Methods

An integrative review of the literature (2016-2022) addressing nurses' experiences in goals of care communication was conducted using PubMed, CINAHL, and PsychInfo databases. A total of 92 articles were retrieved. A total of 12 articles were included for this review after applying the inclusion and exclusion criteria.

Results

Of the 12 articles, the majority were qualitative studies (n = 8). Qualitative analysis of findings from all articles revealed three dominant themes: nurses' ambiguous role responsibilities, goals of care as end-of-life communication, and the need for nurse communication training.

Conclusion

This article suggests an innovative conceptual model for advancing nurse communication about goals of care to facilitate primary palliative care.

Innovation

The framework characterizes two communication pathways for Advanced Practice Nurses who direct goals of care discussions and Registered Nurses who support goals of care communication. The model informs future communication training aimed at supporting primary palliative care.

End-of-life conversations for the older person: A concept analysis

AIM

The aim of this concept analysis is to seek clarity as to what end-of-life conversations involve by developing a clear working definition and using model cases to conceptualise the defining attributes of an end-of-life conversations with the older person.

DESIGN

Walker and Avant's eight step approach to Concept Analysis.

DATA SOURCES

Four databases were searched, including PubMed, CINAHL, PsycINFO, and Scopus. A total of 339 publications were identified with 30 papers meeting the inclusion criteria and put forward for the final conceptual analysis.

RESULTS

The defining attributes associated with end-of life conversations included (1) an ongoing process of older person empowerment, (2) discussion's concerning values and preferences concerning end-of-life issues, and (3) maintaining an open dialogue between all concerned individuals. Antecedents were associated with the older person is their readiness to talk openly about death and dying. Consequences were identified as having a better understanding of what death and dying may mean to the older person in a more specific manner.

CONCLUSIONS

End-of-life conversations are vital in understanding an individual's values and preferences at the end of life, and yet, the concept of the end-of-life conversation has not been well defined in the literature. End-of-life conversations with the older person encompass ongoing discussions and maintaining open dialogue around end-of-life care while developing strategies to promote individual empowerment in making informed choices. Using a conceptual model, aides in addressing aspects of end-of-life conversations and an acknowledgment of the dynamic process of end-of-life conversations.

Health communication and shared decision-making between nurses and older adults in community setting: An integrative review

AIM

To explore the role of health communication in Shared Decision-Making (SDM) between nursing staff and older people in the community setting.

BACKGROUND

Society and healthcare services are marked by an exponentially ageing population, leading to a significant proportion of patients being older adults with highly demanding care needs. Scientific literature supports shared decision-making as a process that engages patients in their care. However, the increasing use of technology and the consequences of the COVID-19 pandemic have influenced how nurses communicate with older patients. Therefore, it is crucial to understand how to develop health communication to reach effective, shared decision-making processes.

METHODS

Whittemore and Knafl's integrative review method, the literature search comprised five databases: PubMed, CINALH, Web of Science, Scopus and PsycINFO.

RESULTS

The 12 included studies were synthesised into three study patterns: (1) nurse-older patient health communication relationship, (2) older patients' perspectives and (3) nontherapeutic communication in end-of-life care.

CONCLUSION

This review underscored the crucial role of effective health communication in shaping SDM dynamics between nursing staff and older people in the community setting. Key elements included transparent information exchange, establishing trust and maintaining communication channels with informal caregiving networks. SDM actions were aligned with preserving older people's autonomy, but communication challenges persisted, particularly in end-of-life situations. Advanced care planning was recommended to address these shortcomings and improve communication among older people, healthcare professionals and families.

IMPLICATIONS

Implementing educational measures based on verbal and nonverbal health communication in nursing training could be beneficial. Nursing research could continue to develop and refine specific communication strategies adapted to the social determinants of health for diverse clinical situations regarding older adults in the community setting.

REPORTING METHOD

The authors have adhered to relevant EQUATOR guidelines through the PRISMA 2020 checklist. No Patient or Public Contribution.

Supporting health and social care professionals in serious illness conversations: Development, validation, and preliminary evaluation of an educational booklet

Serious illness conversations aim to align the care process with the goals and preferences of adult patients suffering from any advanced disease. They represent a challenge for healthcare professionals and require specific skills. Conversation guides consistent with task-centered instructional strategies may be particularly helpful to improve the quality of communication. This study aims to develop, validate, and preliminarily evaluate an educational booklet to support Italian social and healthcare professionals in serious illness conversations. A three-step approach, including development, validation, and evaluation, was followed. A co-creation process with meaningful stakeholders led to the development of the booklet, validated by 15 experts on clarity, completeness, coherence, and relevance. It underwent testing on readability (Gulpease index, 0 = lowest-100 = maximum) and design (Baker Able Leaflet Design criteria, 0 = worst to 32 = best). Twenty-two professionals with different scope of practice and care settings evaluated acceptability (acceptable if score ≥30), usefulness, feasibility to use (1 = not at all to 10 = extremely), and perceived acquired knowledge (1 = not at all to 5 = extremely). After four rounds of adjustments, the booklet scored 97% for relevance, 60 for readability, and 25/32 for design. In all, 18 (81.8%), 19 (86.4%) and 17 (77.3%) professionals deemed the booklet acceptable, moderate to highly useful, and feasible to use, respectively; 18/22 perceived gain in knowledge and all would recommend it to colleagues. The booklet has good readability, excellent design, high content validity, and a high degree of perceived usefulness and acquired knowledge. The booklet is tailored to users' priorities, mirrors their most frequent daily practice challenges, and offers 1-minute, 2-minute and 5-minute solutions for each scenario. The co-creation process ensured the development of an educational resource that could be useful regardless of the scope of practice and the care setting to support professionals in serious illness conversations.

Nurses' Subjectivity in Patient-Centered Communication for End-of-Life Patients

Effective patient-centered communication is essential in providing quality care for patients at the end of life. This study aimed to explore the subjectivity of nurses' communication approaches using Q methodology. In this study, 33 Q-samples were constructed based on in-depth interviews with 12 hospice nurses. The Q classification was performed by a total of 38 hospice nurses who had more than 3 years of experience in hospice settings. The collected data were analyzed through the principal component analysis method and the varimax rotation process using the PQ method program. As a result, a total of 4 distinct types emerged: "sincere listener," "family-centered caregiver," "resource utilization facilitator," and "sufficient time devoter." The factors accounted for 64% of the variance: 19%, 15%, 16%, and 14% respectively. By identifying distinct viewpoints, valuable insights into the diverse perspectives held by nurses in patient-centered communication were gained. Understanding these viewpoints will contribute to the development of tailored communication strategies and training programs. In addition, the study underscores the need for training, resources, and organizational support to enhance nurses' communication skills.

The Effect of Simulation on Nursing Student Perceptions of Readiness to Provide End-of-Life Care

Evidence suggests that nursing students in a prelicensure nursing program lack the required preparation to care for patients at the end of life (EOL), causing feelings of inadequacy and stress. New graduate nurses (years 0-5) struggle to address the needs of this patient population, leading to considering career changes. Nursing simulation has been shown to enhance competency and is gaining increasing favor in prelicensure nursing education. Little research has been conducted on the application of simulation using standardized patients in EOL patient scenarios. This study used live standardized patients who simulated a home health patient encounter with the nursing student acting as a home health hospice nurse. Watson's theory of caring and interpretive phenomenological analysis guided the qualitative research method and analysis. Five students chose to participate in this simulation and completed 6 reflective questions. After simulation, they felt more comfortable having difficult discussions about EOL care, treatment options, and patient fears. Participants noted the importance of communication in a team setting, which included the caregiver as an integral member. The use of standardized patient-simulated experiences increases realism and provides students the opportunity to bridge the gap between didactic education and clinical practice. This will enhance their readiness and confidence in providing EOL care.

Nutrition and Non-Nutrition-Related Challenges Predict Time to Death in Long-Term Care Residents: A Retrospective Chart Review

Purpose

Signals of end-of-life decline observed in daily habits, such as mealtime participation, are important for moving towards comfort-focused goals of care in the final months of life of long-term care (LTC) residents. It is unclear how eating issues observed in real-time in LTC homes are used as indicators of suspected end of life. The study quantifies nutrition and key non-nutrition related signals (eg, general decline, unstable vitals) documented to describe end-of-life decline and the subsequent time to death.

Patients and Methods

A retrospective chart review identified the first documented conversation where end-of-life decline was considered by members of the care team (eg, nurses, physicians, dietitian, family member) for 76 randomly selected decedents from 9 LTC homes in southwestern Ontario, Canada. Time (days) to death was calculated. A directed content analysis of the free-text description of the suspected end-of-life decline was used to categorize signals. Cox proportional hazards regression analysis tested the risk of mortality associated with each categorized signal.

Results

Time to death of residents (mean age = 88 ± 7 years; 60% female) from the first documentation of potential end-of-life decline ranged from 0 days to over 2 years prior to death (median = 27.5 days). Seven nutrition-related and 18 non-nutrition related signals were identified. Swallowing difficulty (HR = 2.99; 95% CI = 1.41, 6.33), cognitive decline (HR = 0.40; 95% CI = 0.20, 0.77), delirium (HR = 13.23; 95% CI = 1.57, 111.69), and cancer (HR = 0.18; 95% CI = 0.07, 0.48) were associated with time to death.

Conclusion

This study provides insight into the signals used by care providers in LTC to suspect that residents are declining towards the end of life and identifies four signals that were associated with time to death. When identified by care providers as indicators of end-of-life decline, swallowing difficulty and delirium predicted a shorter time to death, while cancer and cognitive decline predicted a longer time to death. Recognition of nutrition and non-nutrition related signals may be leveraged to systematically introduce timely comfort care conversations.

'I am still valuable' - A qualitative study of incurable cancer patients coping in hospice care

BACKGROUND

Knowledge of the experiences of coping in patients with incurable cancer is essential for high-quality palliative and end-of-life care.

AIM AND OBJECTIVE

To describe the coping experiences of patients with incurable cancer in hospice care to better develop patient-centred care.

METHODS

The data for this qualitative study were collected through semi structured interviews, with patients with incurable cancer in hospice care (N = 20) and analysed with inductive content analysis. Ethical and organisational approvals were obtained, and the participants received both verbal and written information before consenting to participate.

RESULTS

The patients' coping was enhanced with their involvement in treatment-related decisions. Valuing day-to-day living and coping with emotional stressors helped them accept their own life situations. Accepting their increasing fragility was enhanced by their self-reappraisal. The patients found security in the possibility of receiving support when they needed it. Although the ordinariness of dying in hospice care settings was sometimes too much to bear, they understood dying to be a part of the natural cycle of life. They questioned the responsiveness of healthcare services because they felt that they were not always heard.

STUDY LIMITATIONS

Because this study was limited to a specific population of cancer patients in hospice care, the results might not be generalised to other patient groups with chronic diseases or other palliative care settings.

CONCLUSIONS

The experiences of patients in hospice care of coping with incurable cancer were reminiscent of the common coping process descriptions. Surprisingly, even though participants voiced that they had accepted their situation, dying itself was something they did not find crucial to discuss. The crucial aspects - without being in denial - dealt more with focusing on positive thinking and facing life.

Developing and testing inter-rater reliability of a data collection tool for patient health records on end-of-life care of neurological patients in an acute hospital ward

AIM

Develop and test a data collection tool-Neurological End-Of-Life Care Assessment Tool (NEOLCAT)-for extracting data from patient health records (PHRs) on end-of-life care of neurological patients in an acute hospital ward.

DESIGN

Instrument development and inter-rater reliability (IRR) assessment.

METHOD

NEOLCAT was constructed from patient care items obtained from clinical guidelines and literature on end-of-life care. Expert clinicians reviewed the items. Using percentage agreement and Fleiss' kappa we calculated IRR on 32 nominal items, out of 76 items.

RESULTS

IRR of NEOLCAT showed 89% (range 83%-95%) overall categorical percentage agreement. The Fleiss' kappa categorical coefficient was 0.84 (range 0.71-0.91). There was fair or moderate agreement on six items, and moderate or almost perfect agreement on 26 items.

CONCLUSION

The NEOLCAT shows promising psychometric properties for studying clinical components of care of neurological patients at the end-of-life on an acute hospital ward but could be further developed in future studies.

Lived experiences of end-of-life communication among nursing home staff: An interpretive phenomenological study

AIMS

To explore and understand lived experiences of end-of-life communication among nursing home staff.

DESIGN

Interpretive phenomenological study.

METHODS

In-person, semi-structured, in-depth interviews were conducted from May to August 2021 with 21 nursing home staff members involved in end-of-life communication (four managers, four chief nurses, three chief medical officers, three nurses, three psychologists, two occupational therapists, one chief nurse aide and one nurse aide). Data were analysed by van Manen's hermeneutic approach, which uses the lifeworld existentials of spatiality, corporeality, temporality and relationality to guide reflection on the human experience. Data were reported according to the Consolidated Criteria for Reporting Qualitative Research.

RESULTS

Thirteen categories were identified and framed within the four existentials. Regarding spatiality, end-of-life communication took place in a physical, mental, socio-cultural and professional competence space. With regard to corporeality, interviewees reported difficulties in managing their own feelings and those of family caregivers. For temporality, interviewees reported delays in end-of-life communication due to staffing issues and an increase in urgent and temporary relief admissions to nursing homes. To compensate, they tried to assure that all interactions that did take place were of high quality. Finally, with regard to relationality, interviewees lived end-of-life communication through their relationships with family caregivers and colleagues. The supportive role of colleagues was expressed as teamwork, which helped promote reflexivity about how to tailor communication, manage challenging emotions and situations, set aside time for communication, and prepare family caregivers for death.

CONCLUSION

End-of-life communication was an all-encompassing experience for nursing home staff. The supportive role of colleagues was stressed across all existentials, suggesting that teamwork is essential in delivering effective communication at the end-of-life.

PATIENT OR PUBLIC CONTRIBUTION

There was no patient or public contribution to this study, which addresses the experiences of nursing home staff only.

A Situation-Specific Theory of End-of-Life Communication in Nursing Homes

High-quality end-of-life communication between healthcare professionals (HCPs), patients and/or their family caregivers (FCs) improves quality of life and reduces non-beneficial care at the end of life. Nursing homes (NHs) are among the contexts at the forefront of these conversations. Having a solid theoretical basis for the role of end-of-life communication in NHs in transitioning to palliative-oriented care can offer indications for research, practice, education, and policy related to geropalliative care. This study aimed to develop a situation-specific theory of end-of-life communication in NHs by refining an existing theory. A four-step integrative approach was employed that included: (1) checking the assumptions for theorization; (2) exploring the phenomenon through multiple sources; (3) theorizing; and (4) reporting. All elements of the existing end-of-life communication theory in NHs were confirmed: end-of-life communication improved the understanding of FCs about their relatives' health conditions, shared decision-making, and reflections on the desired preferences of residents/FCs for care at the end of life. Furthermore, the family environment affected the burden of FCs in the decision-making process. Finally, time and resource constraints, regulations, visitation restrictions due to the COVID-19 pandemic, and social and cultural values influenced the quality and timing of communication. The study findings confirmed the impact of the political, historical, social, and cultural context on end-of-life communication, thus providing the basis for a situation-specific theory.

Navigating Disharmony: Nurse Experiences Providing End-of-Life Communication

The purpose of this study was to describe nurses' experiences of communicating with patients and families at end of life (EOL). The COMFORT Communication Model guided this descriptive qualitative study. Participants from 1 major health care system located in the Great Plains completed an online survey, which consisted of Likert-type (N = 252) and open-ended questions (n = 201). This article reports the qualitative findings of this survey. Thematic analysis of the participants' narrative responses revealed an overarching theme of disharmony when caring for patients and families at EOL. We identified 3 themes within the overarching theme of disharmony: navigating denial, words matter, and knowledge deficit. Nurses express discomfort and a knowledge deficit when providing communication specific to primary palliative and EOL care. Nursing education has an obligation to ensure that new graduates are trained in and develop comfort with the communication principles of primary palliative and EOL care. This holistic approach may improve the quality of communication surrounding the EOL experience for patients, families, and nurses.

Challenges Experienced by Italian Nursing Home Staff in End-of-Life Conversations with Family Caregivers during COVID-19 Pandemic: A Qualitative Descriptive Study

End-of-life conversations are among the most challenging of all communication scenarios and on the agenda of several healthcare settings, including nursing homes (NHs). They may be also difficult for experienced healthcare professionals (HCPs). This study explores the difficulties experienced by Italian NH staff in end-of-life conversations with family caregivers (FCs) during COVID-19 pandemic to uncover their educational needs. A qualitative descriptive study based on inductive thematic analysis was performed. Twenty-one HCPs across six Italian NHs were interviewed. Four themes described their experiences of end-of-life conversations: (1) communicating with FCs over the overall disease trajectory; (2) managing challenging emotions and situations; (3) establishing a partnership between HCPs and FCs; (4) addressing HCPs' communication skills needs. HCPs had to face multiple challenging situations that varied across the care period as well as complex emotions such as anxiety, guilt, uncertainty, fear, anger, or suffering, which required tailored answers. COVID-19 pandemic increased FCs' aggressive behaviors, their distrust, and uncertainty due to visitation restrictions. HCPs had to overcome this by developing a set of strategies, including adoption of an active-listening approach, supportive communication, and explicit acknowledgement of FCs' emotions. Since communication needs were mostly practical in nature, HCPs valued practical communication training.

The role of end-of-life communication in contributing to palliative-oriented care at the end-of-life in nursing home

BACKGROUND

Clear communication about a person's poor prognosis and limited treatment choices improves the quality of end-of-life care.

AIMS

To investigate how end-of-life communication may contribute to palliative-oriented care at the end-of-life in nursing homes according to both families' and nurses' perspective. Secondly, to identify the contextual factors internal to the nursing home that may influence the timing and quality of communication. Thirdly, to confirm the foundations for a first theory of end-of-life communication.

METHOD

This study is a descriptive two-tailed embedded multiple-case study. A secondary analysis of 23 family carer-nurse paired interviews was performed.

FINDINGS

Several contextual factors influenced the timing and quality of communication that, in turn, impacted end-of-life care by promoting family understanding, fostering shared decision-making between healthcare professionals and resident/family carers, and improving the knowledge of residents' and family carers' preferences (ie drivers of transition towards palliative-oriented care). Family carers' preferences had the strongest influence in guiding the care approach, while residents' preferences were poorly known and had a limited impact on the end-of-life care goal. Complex and dynamic interactions within and between drivers and contextual factors emerged, providing preliminary evidence for a first end-of-life communication theory.

CONCLUSION

Findings suggest the need to promote a familiar atmosphere and quality relationships, and improve the knowledge of a resident's preferences to ensure that end-of-life care is consistent with their desires.

End-of-life discussions in residential care homes improves symptom control: a national register study

BACKGROUND

In Europe, residential care homes (RCHs) rather than hospitals are the most common care facilities for the older adult and the place where most deaths occur in this age group. There is a lack of knowledge regarding end-of-life (EOL) discussions and how they correlate with symptoms and symptom relief.

OBJECTIVE

The aim was to examine the correlation between EOL discussions and symptom occurrence, symptom relief and prescriptions or PRN drugs against symptoms for care home residents.

METHODS

All expected deaths at RCHs from 1 October 2015 to 31 December 2016 and registered in the Swedish Register of Palliative Care were included. Univariate and multivariate logistic regression were used to compare the RCH residents, or their family members, who had received documented EOL discussions with a physician (the EOL discussion group) and the non-EOL discussion group.

RESULTS

The EOL discussion group (n=17 071) had a higher prevalence of pain, nausea, anxiety, death rattles and shortness of breath reported, compared with the non-EOL discussion group (n=4164). Those with symptoms were more often completely relieved and had more often been prescribed PRN drugs against that symptom in the EOL discussion group. All differences remained significant when adjusting for age, time living in unit and cause of death.

CONCLUSION

The results indicate that EOL discussions are correlated with higher prevalence of symptoms, but also with better symptom relief and prescription of symptom drugs PRN when symptomatic. A possible explanation for this is that the EOL discussion can work as an opportunity to discuss symptoms and treatment for symptom relief.

Qualitative research on end-of-life communication with family carers in nursing homes: A discussion of methodological issues and challenges

Aim

To identify and summarize the challenges of conducting qualitative research exploring end-of-life communication between healthcare providers and bereaved family carers in nursing homes.

Design

A descriptive qualitative study based on in-the-field-notes and research diaries collected during a primary study involving 32 bereaved family carers and 14 nurses across 13 Italian nursing homes in 2018-2019.

Methods

Two trained female nurses conducted semi-structured, in-depth, open-ended interviews and recorded "in action" (i.e. reflections reported as in-the-field-notes) and "on action" (i.e. retrospective reflections within the team reported immediately in the research diaries) narratives, with the aim of identifying challenges encountered during the research process. A content analysis process was performed to analyse the narratives collected.

Results

We identified three major categories of challenges: (a) obtaining approval from the ethical committee; (b) approaching nursing homes and family carers; and (c) dealing with participant-related impairments (i.e. memory, emotional, physical).