"I'm going to push this door open. You can close it": A qualitative study of the brokering work of oncology clinic nurses in introducing early palliative care

Introducing palliative care in advanced cancer: a systematic review

BACKGROUND

Negative perceptions about palliative care (PC), held by patients with cancer and their families, are a barrier to early referral and the associated benefits. This review examines the approaches that support the task of introducing PC to patients and families and describes any evaluations of these approaches.

METHODS

A systematic review with a systematic search informed by the Preferred Reporting Items for Systemic Reviews and Meta-Analyses guidelines was performed on the online databases MEDLINE, PsychInfo and CINAHL from May 2022 to July 2022. Identified studies were screened by title and abstract, and included if they were empirical studies and described an approach that supported the introduction of PC services for adult patients. A narrative-synthesis approach was used to extract and present the findings.

RESULTS

Searches yielded 1193 unique manuscripts, which, following title and abstract screening, were reduced to 31 papers subject to full-text review, with a final 12 studies meeting eligibility criteria. A diverse range of included studies described approaches used to introduce palliative care, which may be broadly summarised by four categories: education, clinical communication, building trust and rapport and integrative system approaches.

CONCLUSION

While educational approaches were helpful, they were less likely to change behaviours, with focused communication tasks also necessary to facilitate PC introduction. An established relationship and trust between patient and clinician were foundational to effective PC discussions. A framework to assist clinicians in this task is likely to be multidimensional in nature, although more quantitative research is necessary to establish the most effective methods and how they may be incorporated into clinical practice.

Strategies Used by Outpatient Oncology Nurses to Introduce Early Palliative Care: A Qualitative Study

BACKGROUND

Although early palliative care is linked to improved health-related quality of life, satisfaction with care, and symptom management, the clinical strategies that nurses use to actively initiate this care are unknown.

OBJECTIVES

The aims of this study were to conceptualize the clinical strategies that outpatient oncology nurses use to introduce early palliative care and to determine how these strategies align with the framework of practice.

METHODS

A constructivist-informed grounded theory study was conducted in a tertiary cancer care center in Toronto, Canada. Twenty nurses (6 staff nurses, 10 nurse practitioners, and 4 advanced practice nurses) from multiple outpatient oncology clinics (ie, breast, pancreatic, hematology) completed semistructured interviews. Analysis occurred concurrently with data collection and used constant comparison until theoretical saturation was reached.

RESULTS

The overarching core category, pulling it all together, outlines the strategies used by oncology nurses to support timely palliative care referral, drawing on the coordinating, collaborating, relational, and advocacy dimensions of practice. The core category incorporated 3 subcategories: (1) catalyzing and facilitating synergy among disciplines and settings, (2) promoting and considering palliative care within patients' personal narratives, and (3) widening the focus from disease-focused treatment to living well with cancer.

CONCLUSION

Outpatient oncology nurses enact unique clinical strategies, which are aligned with the nursing framework and reflected multiple dimensions of practice, to introduce early palliative care.

IMPLICATIONS FOR PRACTICE

Our findings have clinical, educational, and policy implications for fostering the conditions in which nurses are supported to maximize their full potential in the introduction of early palliative care.

"We're Cancer Care Nurses": Perceptions About Providing Palliative Care in a Community Hospital

Nurses play a key role in integrating palliative care into oncology. This project sought to better understand oncology nurses' perspectives about palliative care. Nurses from a community hospital were presented with a series of clinical scenarios and asked to comment on the appropriateness of palliative care in each case. A series of focus groups were held, inviting nurses' reflections about palliative care in relation to their practice. Nurses commenting on the clinical scenarios were unanimous that palliative care was appropriate in the most straightforward case: older adult, approaching the terminal phase of a cancer, having exhausted all curative treatment options, accepting death, wanting comfort, and contending with difficult symptoms. However, opinions on appropriateness varied in less straightforward cases, such as when patients did not accept death or when their cancer diagnosis was recent. In focus groups, nurses described a hybrid professional identity that integrates both oncology and palliative care. To them, this integration constituted the meaning of "cancer care." They further reflected on tensions they experience between their proximity to patients in everyday care and their (in)abilities to meet palliative care needs. Results suggest the need for stronger institutional supports of cancer nurses' palliative practice.

Development of the palliative care referral system: proposal of a tool for the referral of cancer patients to specialized palliative care

BACKGROUND

Early palliative care (PC) has shown beneficial effects for advanced cancer patients. However, it is still debated what criteria to use to identify patients for PC referral.

AIM

To document the initial steps of the development of the Palliative Care Referral System (PCRS), a tool to be used by oncologists in clinical practice.

METHODS

A multiprofessional working group developed the PCRS based on the results of a scoping literature review on PC referral criteria. PCRS criteria were evaluated by experts via a nominal group technique (NGT). Descriptive statistics were used to summarize expert scores on relevance, appropriateness and perceived feasibility of the criteria proposed. Quotations of participants during the discussion were also reported.

RESULTS

Sixteen studies, including PC referral criteria/tools, emerged from the scoping review. Severe symptoms, poor performance status, comorbidities and prognosis were the most commonly used criteria. The PCRS included nine major criteria and nine assessment methods; a scoring procedure was also proposed. Answers to the questionnaire during the NGT showed that five criteria reached full agreement on all items, while four did not, and were then discussed within the group. Participants agreed on the relevance of all criteria and on the appropriateness of methods proposed to assess most of them, while issues were raised about potential feasibility of the overall assessment of the PCRS in clinical practice.

CONCLUSION

The PCRS has been developed as an help for oncologists to timely identify patients for specialized PC referral. Since feasibility emerged as the main concern, implementation strategies have to be tested in subsequent studies.

Patient, Family Caregiver, and Nurse Involvement in End-of-Life Discussions During Palliative Chemotherapy: A Phenomenological Hermeneutic Study

The aim of this study was to investigate current nursing practice related to end-of-life discussions with incurable lung cancer patients and their family caregivers from the perspectives of patients, family caregivers, and nurses in an oncology outpatient clinic. This phenomenological hermeneutic study included nine patients, eight family caregivers, and 11 nurses. Data were collected using participant observation, informal and semi-structured individual or joint interviews with patients and family caregivers, and focus group interviews with nurses. A Ricoeur-inspired approach was used to analyze the data. Three themes were identified: (a) content of end-of-life discussions, (b) timing of end-of-life discussions, and (c) challenges in end-of-life discussions. End-of-life discussions were seldom initiated; when they were, it was often too late. Discussions addressed treatment, place of care, practical/economic concerns, and existential matters. The physical environment at the outpatient clinic, lack of continuity, and nurses' instrumental task workloads and time pressure posed challenges to initiating end-of-life discussions.

Paediatric oncology ward nurses' experiences of patients' deaths in China: A qualitative study

BACKGROUND

Considering cancer death is second only to accidental death in the number of lives claimed each year,nurses in paediatric oncology wards often experience helplessness, sadness, frustration and such other adverse emotions when they witness children's death due to cancer.However,there is a lack of qualitative studies on nurses who witness the death of children in paediatric oncology wards in China.

METHOD

A qualitative study was conducted using a semi-structured interview guide with 22 paediatric oncology ward nurses. Interviews were recorded and simultaneously translated and transcribed. Thematic analysis was used to analyse the data.

RESULTS

The analysis resulted in the identification of three main thematic categories: Different emotional expression, Different copingstrategies, A weak support system. Nursing managers should pay attention to problems faced by nurses in paediatric oncology wards, and take targeted measures in terms of continuing training courses, improving the psychological adaptability of oncology professional nurses, and providing them substantive support.

CONCLUSION

Nurses in paediatric oncology wards have strong stress responses to facing the death of children. They reported experiencing complex psychological feelings and have different coping attitudes. Healthcare authorities should recognise and understand the needs of paediatric oncology ward nurses, who often witness the death of children. Appropriate and effective support measures should be planned and implemented for these nurses to maintain their mental health, thus enabling them to better serve patients.

An integrative review to identify how nurses practicing in inpatient specialist palliative care units uphold the values of nursing

Background

Caring for individuals and their families with a life-limiting, symptomatic illness and those who are dying has long been an integral role of palliative care nurses. Yet, over the last two decades, the specialty of palliative care has undergone significant changes in technology and medical treatments which have altered both the disease trajectory and the delivery of palliative care. To date, there is little evidence as to the impact of these medical and nursing advancements on the role of nurses working in palliative care and how in clinical practice these nurses continue to uphold their nursing values and the philosophy of palliative care.

Methods

An integrative review was conducted searching seven academic databases from the time period of January 2010 – December 2019 for studies identifying research relating to the role of the palliative care nurse working in specialist palliative care units and hospices. Research articles identified were screened against the inclusion criteria. Data extraction was completed on all included studies and the Crowe Critical Appraisal Tool was utilized to appraise the methodological quality and thematic analysis was performed guided by Braun and Clarke’s framework. The review was conducted and reported in lines with PRISMA guidelines.

Results

The search yielded 22,828 articles of which 7 were included for appraisal and review. Four themes were identified: (1) enhancing patient-centred care (2) being there (3) exposure to suffering and death (4) nursing values seen but not heard. The findings highlight that while palliative care nurses do not articulate their nurse values, their actions and behaviors evident within the literature demonstrate care, compassion, and commitment.

Conclusion

These findings suggest that there is a need for nurses working in specialist palliative care units to articulate, document, and audit how they incorporate the values of nursing into their practice. This is pivotal not only for the future of palliative nursing within hospice and specialist palliative care units but also to the future of palliative care itself. To make visible the values of nursing further practice-based education and research is required.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00810-6.

Nurses' involvement in end-of-life discussions with incurable cancer patients and family caregivers: An integrative review

AIM

To review current evidence of nurses' involvement in end-of-life discussions with incurable cancer patients and their family caregivers.

DESIGN

We conducted a systematic integrative review in accordance with PRISMA guidelines: PROSPERO, registration number: CRD42020186204.

DATA SOURCES

CINAHL, Medline, PsycInfo, Embase. We searched for primary research between 2010 and 2020.

RESULTS

Of 3,271 references, we found 15 eligible articles: qualitative (n = 12) and quantitative (n = 3). The studies focused on oncology nurses' perspective of involvement in end-of-life discussions. The data analysis resulted in four overall themes: (1) Nursing roles; the advocating, supporting, and reframing roles, and an undefined task, for example in medical consultations, (2) Trust building, (3) Nurse competences, and (4) Medical issues.

SIGNIFICANCE OF RESULTS

The nurses have several roles in end-of-life discussions, but insufficient competencies to be involved in that kind of discussions, for example to involve and communicate with families. The findings implicate an educational need among the nurses. However, it also points toward an organizational change in the outpatient clinics, for example that end-of-life discussions follow a more structured approach, are offered in a scheduled manner, and that nurses invite the family caregivers to attend.

European Cancer Organisation Essential Requirements for Quality Cancer Care (ERQCC): Pancreatic Cancer

European Cancer Organisation Essential Requirements for Quality Cancer Care (ERQCC) are written by experts representing all disciplines involved in cancer care in Europe. They give patients, health professionals, managers and policymakers a guide to essential care throughout the patient journey. Pancreatic cancer is an increasing cause of cancer mortality and has wide variation in treatment and care in Europe. It is a major healthcare burden and has complex diagnosis and treatment challenges. Care must be carried out only in pancreatic cancer units or centres that have a core multidisciplinary team (MDT) and an extended team of health professionals detailed here. Such units are far from universal in European countries. To meet European aspirations for comprehensive cancer control, healthcare organisations must consider the requirements in this paper, paying particular attention to multidisciplinarity and patient-centred pathways from diagnosis, to treatment, to survivorship.

Models of Integration of Specialized Palliative Care with Oncology

OPINION STATEMENT

Evidence from randomized controlled trials and meta-analyses has shown that early integration of specialized palliative care improves symptoms and quality of life for patients with advanced cancer. There are various models of early integration, which may be classified based on setting of care and method of palliative care referral. Most successful randomized controlled trials of early palliative care have used a model of specialized teams providing in-person palliative care in free-standing or embedded outpatient clinics. During the COVID-19 pandemic, telehealth has become a prominent model for palliative care delivery. This model of care has been well received by patients and palliative care providers, although evidence to date is limited. Despite evidence from trials that routine early integration of palliative care into oncology care improves patient outcomes, referral to palliative care still occurs mostly according to the judgment of individual oncologists. This hinders equitable access to palliative care and to its known benefits for patients and their caregivers. Automated referral based on triggering criteria is being actively explored as an alternative. In particular, routine technology-assisted symptom screening, combined with targeted needs-based automatic referral to outpatient palliative care, may improve integration and ultimately increase quality of life.

Nursing education on palliative care across Europe: Results and recommendations from the EAPC Taskforce on preparation for practice in palliative care nursing across the EU based on an online-survey and country reports

BACKGROUND

Nurses are the largest regulated group of healthcare professionals involved in palliative care. In 2004, a taskforce of the European Association for Palliative Care (EAPC) launched the 'Guide for development of palliative nurse education in Europe' (hereinafter, the EAPC 2004 Guide). No systematic evaluation of its impact in the development of palliative care education was undertaken.

AIMS

To describe current undergraduate and postgraduate nursing education across Europe; to identify the roles that nurses with different palliative care educational levels have in palliative care; and to assess the uptake of the EAPC 2004 Guide in the development of palliative care nursing in Europe.

DESIGN

Descriptive research involving an online survey among nursing experts, and the consultation of national representatives.

SETTING/PARTICIPANTS

A total of 135 nurses (52% response rate) from 25 countries completed the online survey; representatives from 16 countries were consulted.

RESULTS

In 14 (56%) countries, palliative care was not identified as a mandatory subject within undergraduate nursing education. The EAPC 2004 Guide is widely known and was/is being used in many countries to promote palliative care nursing education. Large variations were found across and within country responses.

CONCLUSIONS

Palliative care nursing education varies largely in Europe. The wide awareness and use of the EAPC 2004 Guide show how policy measures can influence the development of palliative care education. Recommendations are built and focus on both fostering the use of this guide and implementing policy measures to ensure that palliative care nursing is recognised and certified as a specialty in all European countries.