"At Least I Can Push this Morphine": PICU Nurses' Approaches to Suffering Among Dying Children

CONTEXT

Parents of children who die in the pediatric intensive care unit (PICU) carry memories of their child's suffering throughout a lifelong grieving experience. Given their prolonged time at the bedside, PICU nurses are poised to attend to dying children's suffering.

OBJECTIVES

We aimed to explore how PICU nurses identify, assess, and attend to EOL suffering.

METHODS

Interpretive descriptive qualitative study with thematic analysis of virtual focus groups from a geographically diverse sample of PICU nurses.

RESULTS

Nurses participated in five focus groups (N = 19). Most identified as White (89%) females (95%) with a range of 1-24 years of PICU experience and involvement in >10 EOL care cases (89%). Nurses described approaches to suffering within five themes: 1) Identifying and easing perceptible elements; 2) Recognizing and responding to subtleties moment-to-moment; 3) Acclimating to family interdependence; 4) Synchronizing nurse in-the-room insight with systemic complexity; and 5) Accounting for ambiguity. Nurses detailed elements of suffering they could "fix" with straightforward, external interventions (e.g., pain medication). More complex tasks like optimizing care within familial and interprofessional team relationships while navigating psychosocial responses from children and families challenged nurses. Nurses attempted to minimize EOL suffering amidst ambiguity and complexity using internal processes including managing the environment and titrating moment-to-moment care.

CONCLUSIONS

While physical suffering may be remedied with direct nursing care, holistically attending to EOL suffering in the PICU requires both bolstering external processes and strengthening PICU nurses' internal resources. Improving psychosocial training and optimizing interprofessional care systems could better support dying children and their families.

Psychometric properties of the Positive Thinking Skills Scale among undergraduate nursing students

Increasing the resilience of undergraduate nursing students is essential for the individual student's well-being and the healthcare system dealing with a looming nursing shortage. Undergraduate nursing students have reported that positive thinking and positive reframing are ways of coping with exposure to suffering, but measurement of these skills remains limited in this population. This is the first study to examine the psychometric properties of the Positive Thinking Skills Scale specifically in undergraduate nursing students and in a sample that includes students from both public and private universities. Internal consistency was demonstrated with a Cronbach's alpha of 0.824, convergent validity was demonstrated with correlations with measures of views of suffering and professional quality of life, and the one-factor structure was supported in a sample of 157 undergraduate nursing students. The Positive Thinking Skills Scale can be a useful tool to both assess and measure the development of positive thinking skills in undergraduate nursing students.

Nonphysical Suffering: An Under-Resourced and Key Role for Hospice and Palliative Care Social Workers

This article highlights recent research findings that have significance for hospice and palliative care social work in Canada, and for the field of hospice and palliative care more broadly. A 2020 discourse analysis study examined the experiences of 24 interdisciplinary palliative care clinicians across Canada in their work with patients' nonphysical suffering. Nonphysical suffering is suffering that may be emotional, psychological, social, spiritual and/or existential in nature. The study found an absence of specialist social workers on hospice and palliative care teams or limited time for specialist social workers to address patients' nonphysical suffering due to high caseloads and complex practical needs. While the study recognizes social workers have expertise in supporting patients' nonphysical suffering, a competency and skill that has not been sufficiently captured in the existing literature, the systemic barriers they face in providing care may leave patients' needs unmet. The study also highlights the unique pressure social workers may feel to relieve patients' nonphysical suffering due to the psychosocial focus of their role. The need for specialist social workers to be included and adequately resourced on hospice and palliative care teams across diverse settings in Canada is evident.

Existential Care in Daily Nursing Practice

ABSTRACT

Relationship-centered palliative nursing during serious illness requires existential care. Yet, multilevel systemic barriers hinder nurses' ability to provide this care. The authors suggest ways to navigate these barriers, highlighting existential care priorities that nurses can attend to in their daily practice. These include 1) maintaining a strengths-based orientation, 2) taking a life course perspective, 3) grounding care firmly in relationships, and 4) responding moment to moment. They propose that by emphasizing existential care in palliative nursing, we can create a more compassionate and human-centered health system.

Palliative care and its own identity, through an autoethnography: do you recognize these patterns?

Introduction:

After more than 25 years working in palliative care (PC) observing thousands of patients and family behaviors, I use my long experience and notes as a source of data for a qualitative research study. The aim is to identify frequent families’ behavior patterns in PC and better describe the culture in PC.

Methods:

This article is part of a larger project, using autoethnography as methodology, with the aim of helping doctors and interested health professionals better understand the culture and reality of PC. The focus is not the author but patients and families’ patterns of social behavior – the social context – within the end-of-life period and how to deal with these professionally. Confidentiality and privacy of patients’ data were guaranteed.

Results:

The vast number of treated cases, the regular observation and recording, and the continuous reflection and analysis over many years have led to these results. Due to editorial restrictions, in this article I only describe four of at least eight typical scenarios I have identified. Each is given a short title and I explore some of their inside-issues, integrating previous knowledge, research, and explanations, with practical suggestions on how to deal with them.

Significance:

As far as we know, these scenarios/patterns have never been described in this way. This work expands knowledge, innovates, and contributes to better describing PC culture. The final goal is to create a set of scripts that can be used to help clinicians quickly identify the clinical situation and how to deal with it in clinical practice. Reflecting on how patients and families frequently behave in PC can be very useful and then teach other professionals to better deal with these challenges.

"If it's the time, it's the time": Existential communication in naturally-occurring palliative care conversations with individuals with advanced cancer, their families, and clinicians

OBJECTIVE

To explore how patients with advanced cancer, their families, and palliative care clinicians communicate about existential experience during palliative care conversations.

METHODS

We analyzed data from the Palliative Care Communication Research Initiative (PCCRI) - a multisite cohort study conducted between 2014 and 2016 involving hospitalized adults with advanced cancer who were referred for inpatient palliative care consultations at two academic medical centers. We used a qualitative descriptive approach paired with inductive content analysis to analyze a random subsample of 30 patients from the PCCRI study (contributing to 38 palliative care conversations).

RESULTS

We found existential communication to be woven throughout palliative care conversations, with key themes related to: 1) time as a pressing boundary; 2) maintaining a coherent self; and 3) connecting with others.

CONCLUSION

Communication about existential experience is omnipresent and varied in palliative care conversations between individuals with advanced cancer, their families, and clinicians.

PRACTICE IMPLICATIONS

Clinicians can recognize that discussion of time, routines of daily life, and relationships in the clinical context may hold profound existential relevance in palliative care conversations. Understanding how patients and families talk about existential experience in conversation can create opportunities for clinicians to better meet these needs.

Hospice social workers' perception of being valued by the interdisciplinary team and the association with job satisfaction

Being valued and respected by colleagues is an important contributor to job satisfaction in hospice and other health care settings. The purpose of this study was to examine how the perception of feeling valued by different members of the interdisciplinary team and interdependence of team members are related to hospice social workers' job satisfaction. The study aims were to examine: (1) the degree to which hospice social workers feel valued by other members of the interdisciplinary team; and 2) whether this is associated with job satisfaction. A nonprobability sample of 203 hospice social workers completed an online survey assessing job satisfaction, perception of feeling valued by each of the professionals on the interdisciplinary hospice team, interdependence of team members, and professional and personal characteristics. The final regression model for intrinsic job satisfaction included feeling valued by doctors and by other social workers, and interdisciplinary interdependence. The final model for extrinsic job satisfaction did not include any of the perception of feeling valued by others on the interdisciplinary team, although interdependence and the number of social workers at the hospice were significant in this model. Reasons for the difference in these models and the practice and policy implications are discussed.