Negotiating futility, managing emotions: nursing the transition to palliative care

Maneuvering between cultures: The reception of hospice care in the Chinese medical community

The expansion of hospice care worldwide has been received differently by medical communities in different societies. Nonetheless, existing efforts to explain how culture affects the reception of hospice care are inadequate. On the basis of fieldwork conducted in Chinese medical institutions and care facilities between 2017 and 2022, this paper draws on a theoretical framework that distinguishes between declarative culture and nondeclarative culture at the personal level to explain the discrepancies between healthcare professionals' beliefs regarding the value of hospice care and their daily healthcare practice. Moreover, this paper uses the concept of cultural scaffolding to demonstrate that the culture of hospice care and the culture of medical institutions are not separate, independent entities but rather evolve together to produce new and local forms of hospice care in the Chinese context. This analysis helps clarify the obstacles and opportunities associated with hospice care in China and contributes to existing research on the reception of hospice care worldwide.

Sense of failure in end of life care: Perspectives from physicians and nurses

Limited knowledge exists regarding sensed failure resulting provision of end-of-life (EOL) care. Among medical health professionals (MHP), a sense of failure is associated with impaired patientcare and reduced worker wellbeing, including higher rates of burnout and secondary traumatic stress. As part of a larger mixed-methods study on the effects of EOL-care provision on MHP in general hospitals, semi-structured in-depth interviews were conducted with 22 physicians and nurses at three tertiary Israeli hospitals, representing a wide range of medical specialties, training, experience, and cultural backgrounds. Qualitative thematic analysis of the interviews led to the identification of the theme 'sense of failure' with the sub-themes 'sources' and 'lived meanings' of the sensed failure. Apart from the source 'losing a patient' all other identified sources were recognized as work-related risk factors, including 'unsupportive environments' and 'shortcomings of the medical practice.' Two of the lived meaning 'sense of personal responsibility' and 'moral injury' were also recognized as work-related risk factors. Surprisingly, albeit the adverse context of EOL-care, the two remaining lived meanings 'learning from failure' and 'sense of purpose' were recognized as protective resilience factors. Changes in workplace norms by focusing on leadership and mentoring programs and implementation of evidence based interventions aimed at reducing the sense of failure and enhancing feelings of purpose are recommended. Finally, the findings described in the study would benefit from continued studies on larger scales.

Nurse-led supportive Coordinated Transitional Care (CTraC) program improves care for veterans with serious illness

BACKGROUND

The Coordinated Transitional Care (CTraC) program is a telephone-based, nurse-driven program shown to decrease readmissions. The aim of this project was to implement and evaluate an adapted version of CTraC, Supportive CTraC, to improve the quality of transitional and end-of-life care for veterans with serious illness.

METHODS

We used the Replicating Effective Programs framework to guide adaptation and implementation. An RN nurse case manager (NCM) with experience in geriatrics and palliative care worked closely with inpatient and outpatient care teams to coordinate care. Eligible patients had a life-limiting diagnosis with substantial functional impairment and were not enrolled in hospice. The NCM identified veterans at VA Boston Healthcare System during an acute admission and delivered a protocolized intervention to define care needs and preferences, align care with patient values, optimize discharge plans, and provide ongoing, intensive phone-based case management. To evaluate efficacy, we matched each Supportive CTraC enrollee 1:1 to a contemporary comparison subject by age, risk of death or hospitalization, and discharge diagnosis. We used Kaplan-Meier plots and Cox-Proportional Hazards models to evaluate outcomes. Outcomes included palliative and hospice care use, acute care use, Massachusetts Medical Orders for Life Sustaining Treatment documentation, and survival.

RESULTS

The NCM enrolled 104 veterans with high protocol fidelity. Over 1.5 years of follow-up, Supportive CTraC enrollees were 61% more likely to enroll in hospice than the comparison group (n = 57 vs. 39; HR = 1.61; 95% CI = 1.07-2.43). While overall acute care use was similar between groups, Supportive CTraC patients had fewer ICU admissions (n = 36 vs. 53; p = 0.005), were more likely to die in hospice (53 vs. 34; p = 0.008), and twice as likely to die at home with hospice (32.0 vs. 15.5; p = 0.02). There was no difference in survival between groups.

CONCLUSIONS

A nurse-driven transitional care program for veterans with serious illness is feasible and effective at improving end-of-life outcomes.

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.

The relationship between emotional intelligence and organizational commitment among nurses working in governmental hospitals in Jordan

INTRODUCTION

Nurses' emotions and feelings in response to their environment and their ability to manage their emotions can significantly affect several aspects of their job. In Jordan, studies are still investigating whether emotional intelligence is significantly related to organizational commitment.

AIM

To investigate whether a significant relationship exists between emotional intelligence and organizational commitment among Jordanian nurses working in governmental hospitals in Jordan.

METHODS

The study used a descriptive cross-sectional correlational design. A convenience sampling method was used to recruit participants working in governmental hospitals. A total of 200 nurses participated in the study. A participant information sheet developed by the researcher was used to obtain the participants' socio-demographic characteristics, the Emotional Intelligence Scale (EIS) developed by Schutte and colleagues, and the Organizational Commitment Scale developed by Meyer and Allen were utilized for data collection.

RESULTS

Participants had high levels of emotional intelligence (M, SD = 122.3, 14.0) and moderate levels of organizational commitment (M, SD = 81.6, 15.7). Emotional intelligence had a significant, positive relationship with organizational commitment (r = 0.53, p < 0.01). Male nurses, widowed nurses, and nurses with higher postgraduate qualifications demonstrated significantly higher levels of emotional intelligence and organizational commitment than female nurses, single nurses, and nurses with undergraduate degrees (p < 0.05).

CONCLUSION

Participants in the current study were highly emotionally intelligent and moderately committed to their organizations. Policies supporting the implementation of interventions to improve organizational commitment and maintain a high level of emotional intelligence should be developed and promoted by nurse managers and hospital administrators, as well as decision-makers should magnet the nurses with postgraduate degrees at clinical sites.

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.

Factors Associated with Behaviors Toward End-of-life Care Among Chinese Oncology Nurses: A Cross-Sectional Study

PURPOSE

The goal of this study was to describe the current status of oncology nurses' behaviors toward end of life (EOL) care in China and to explore the factors associated with oncology nurses' behaviors toward EOL care.

METHODS

A cross-sectional design was applied and a convenience sample of 1038 oncology nurses from 22 grade A hospitals were recruited into this study. A general social demographic data questionnaire was administered, and the Chinese version of Nurses' Behaviors of Caring for Dying Patients Scale was used to assess nurse behavior toward EOL care. The total score ranges from 40 to 200 points. Data were analyzed with SPSS 26.0 software.

RESULTS

Chinese oncology nurses' average score of holistic EOL care behaviors was 2.97 ± 0.59. Oncology nurses provide physical care most (3.81 ± 0.76), followed by family care (3.02 ± 0.86), and spiritual care (2.37 ± 0.67). Multiple regression analysis showed that a higher frequency of sharing EOL care experience with colleagues, in-service palliative care education, higher level of head nurse support for EOL patient care, more cases of EOL care, higher working position, and nurse's perceived high level of support were positively associated with behavior toward EOL care. These six factors explained 16.2% of the total variance.

CONCLUSIONS

The results may help provide a basis for converting behavior for EOL care among oncology nurses and design interventions to better improve quality of life for EOL patients with cancer in China.

Nursing students' attitudes towards death and caring for dying patients

Aim

To examine the attitudes of undergraduate Jordanian nursing students towards death and caring for dying patients.

Design

A cross‐sectional correlational design.

Methods

The Frommelt Attitude Toward Care of the Dying and Death Attitude Profile‐Revised scales were used in this study with a convenience sample of 555 students from nursing schools in Jordan.

Results

Nursing students had positive attitudes towards death (M = 153.7, SD = 21.5) and a positive attitude towards caring for dying patients (M = 98.1, SD = 9.2). Fear of death, escape acceptance and death avoidance were significant negative predictors, while neutral acceptance, higher academic level and female gender were significant positive predictors of caring for dying patients (F = 4.5).

Conclusion

Nursing students had positive attitudes towards caring for dying patients that was influenced by university type, academic level and gender. Nursing education must further focus on death, dying and end‐of‐life care across the core courses of nursing curricula, theory and practicum.

Continuums of Change in a Competence-Building Initiative Addressing End-of-Life Communication in Swedish Elder Care

Conversations about values for the end-of-life (EoL) between residents, relatives, and staff may allow EoL preparation and enable value-concordant care, but remain rare in residential care home (RCH) practice. In this article, longitudinal qualitative analysis was used to explore changes in staff discussions about EoL conversations throughout workshop series based on reflection and knowledge exchange to promote EoL communication in RCHs. We identified three overall continuums of change: EoL conversations became perceived as more feasible and valuable; conceptualizations of quality EoL care shifted from being generalizable to acknowledging individual variation; and staff's role in facilitating EoL communication as a prerequisite for care decision-making was emphasized. Two mechanisms influenced changes: cognitively and emotionally approaching one's own mortality and shifting perspectives of EoL care. This study adds nuance and details about changes in staff reasoning, and the mechanisms that underlie them, which are important aspects to consider in future EoL competence-building initiatives.

Palliative care competencies and education needs of nurses and healthcare assistants involved in the provision of supportive palliative care

BACKGROUND

This paper investigates the palliative care competencies (knowledge, behaviours, attitudes) and education needs of nurses and healthcare assistants (HCAs) who provide supportive (Level 2) palliative care.

METHODS

A mixed-methods study using a sequential exploratory design was used, with findings integrated across sources. Qualitative focus groups were conducted in 2018 with a sample of staff (n=11, all female; nurses=4; HCAs=7) providing supportive palliative care in a single service setting. A quantitative survey, also conducted in 2018, explored the issue with a wider sample within the same setting (n=36; nurses=18; HCAs=18; female=32).

RESULTS

Qualitatively, communication was highlighted as an important domain of the competence framework, with many participants acknowledging that the ability to communicate effectively is essential. Quantitatively, participants scored in the lower range for competency variables. A significant difference was observed between HCAs and nurses on measures of knowledge (t= -2.718; df=30; p<.05) and behaviour (t=-3.576; df=30; p<.05), with HCAs scoring significantly higher than nurses. In relation to education, while some participants report being indecisive regarding engaging in education/training, others highlighted the benefit of education, especially its ability to impact on their current practice.

CONCLUSION

This research contributes to understanding palliative care competencies among nurses and HCAs working in palliative care, and has important implications for the education and training of nurses and HCAs working in Level 2 palliative care in Ireland.

Placing death and dying: Making place at the end of life

Over the last decade, policies in both the UK and many other countries have promoted the opportunity for patients at the end of life to be able to choose where to die. Central to this is the expectation that in most instances people would prefer to die at home, where they are more likely to feel most comfortable and less medicalised. In so doing, recording the preferred place of death and reducing the number of hospital deaths have become common measures of the overall quality of end of life care. We argue that as a consequence, what constitutes a desired or appropriate place is routinely defined in a very simple and static 'geographical' way, that is linked to conceptualising death as an unambiguous and discrete event that happens at a precise moment in time in a specific location. In contrast, we draw on 18 months of ethnographic fieldwork with two inner-London palliative care teams to describe the continual work staff do to make places suitable and appropriate for the processes of dying, rather than for a singular event. In this way, instead of 'place of death' merely defined in geographic terms, the palliative care staff attend to the much more dynamic relation between a patient and their location as they approach the end of their life. Central to this is an emphasis on dying as an open-ended process, and correspondingly place as a social space that reflects, and interacts with, living persons. We propose the term 'placing work' to capture these ongoing efforts as a patient's surroundings are continually altered and adjusted over time, and as a way to acknowledge this as a significant feature of the care given.

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.

A survey on the training needs of caregivers in five European countries

AIM

This survey explored caregivers' perceived training needs in 5 European countries (United Kingdom, Greece, Bulgaria, Poland and Italy).

BACKGROUND

Training can enhance the professional capacity of caregivers; however, caregivers' training needs within Europe have not been examined recently.

METHODS

A survey conducted in 2015 captured data from 550 caregivers using a convenience sampling strategy, through a structured questionnaire and additional open-ended items and by conducting statistical and content analysis.

RESULTS

The results indicated basic nursing skills and specialization, as well as training in psychology-related skills like time management, emotion regulation, communication and advanced health care systems as the emerging training needs. There were some country differences in specific training need areas.

CONCLUSIONS

It was concluded that training in basic nursing skills and specialization in nursing specific conditions, in advanced health care systems and in psychology-related skills could add to the professional capacity of European caregivers employed in health and social care.

IMPLICATIONS FOR NURSING MANAGEMENT

The findings inform about employed caregivers' training needs in Europe, which may contribute in the provision of quality care and organisational efficiency in health and social care.

"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

BACKGROUND

Early palliative care improves quality of life during life-prolonging treatment for patients with cancer, but the role of nurses in facilitating the early involvement of palliative care is unclear.

AIM

To conceptualize the psychosocial processes involved in the introduction and provision of palliative care by oncology nurses.

DESIGN

A constructivist qualitative grounded theory study was conducted.

SETTING/PARTICIPANTS

A total of 20 nurses (6 staff nurses, 10 nurse practitioners, and 4 advanced practice nurses) completed semi-structured interviews. Participants were from multiple ambulatory care oncology clinics (i.e. breast, pancreatic, hematology) in a comprehensive cancer center.

RESULTS

The core category, brokering palliative care, represented the overarching concept of the study that linked other subcategories. The other subcategories were as follows: opening the door-creating the possibility of discussing early palliative care at a time when patients show signs of being receptive to this discussion; building trust-establishing relationships with patients as a starting point for open discussions about palliative care; tackling misconceptions-addressing patients' assumptions about palliative care as signifying death; and advocating with oncologists-seeding the process of referral by bringing patients' concerns forward.

CONCLUSION

Oncology nurses play a central role in "brokering" the introduction of early palliative care; this process is supported by their relational proximity to patients and their location "in between" the patient and the oncologist. Training all nurses in palliative care and empowering them to have proactive discussions in a collaborative practice context would allow greater access to early palliative care.

Recovery experiences buffer against adverse well-being effects of workplace surface acting: A two-wave study of hospital nurses

AIMS

To test the direct effects of different surface acting strategies and the interactive effects of surface acting and recovery experiences on nurses' well-being.

DESIGN

A two-wave study design.

METHODS

Chinese hospital nurses (N = 372; 47.3% of initial sample) reported on their levels of surface acting, recovery experiences and well-being using a paper and pencil survey in November 2017 and November 2018.

FINDINGS

Surface acting has long-term effects on nurses' well-being. Compared with positive expression, negative suppression generally tends to show more negative effects. Recovery experiences play a buffering role in the surface acting - nurses' well-being relationship.

CONCLUSION

These findings offer initial evidence for long-term effects of surface acting and show how hospital nurses can avoid adverse effects of surface acting through fostering recovery experiences.

IMPACT

Surface acting is a chronic stressor, having long-term effects on nurses' well-being. In contrast to positive expression, negative suppression has more detrimental impacts. Recovery experiences play a protective role by alleviating the adverse effects of surface acting. Managers and individuals are advised to differentiate distinct surface acting strategies. Managers should try best to facilitate employee recovery. Hospital nurses are well recommended to train themselves by adopting several recovery programmes.

Psychological Issues of Patient Transition from Intensive Care to Palliative Care

End-of-life care in the intensive care unit is fraught with complicated psychological responses by patients, families, and staff. Empathic and mindful communication, inclusion of all integral staff in decision-making meetings, and multidimensional support of patients and families can ease the transition away from aggressive life-prolonging to comfort-oriented end of life care. Primary palliative care communication strategies can help clarify goals of care and facilitate transitions. Early integration of specialist palliative care is recommended.

Continuous, comprehensive and crucial care: The role of the CNS in the metastatic castration-resistant prostate cancer patient pathway

Several treatment options are now available to men with metastatic castration-resistant prostate cancer (mCRPC). While survival rates for mCRPC continue to improve, patients are faced with increasingly complex treatment pathways and decisions. The clinical nurse specialist (CNS) plays a crucial role in navigating patients with mCRPC through their treatment pathway and fulfils a number of key responsibilities, including providing holistic care and support to patients and their families, educating and communicating with them in a timely and effective manner, and liaising with other healthcare professionals to seamlessly coordinate patient treatment. However, increasing patient caseloads and administrative duties are leaving CNSs with little time to fulfil their supportive role. Additional resources are needed in order to both promote and preserve this supportive role, thus ensuring that mCRPC patients receive the best possible care.

Home Care Workers' Experiences of Client Death and Disenfranchised Grief

While many types of health care workers experience patient death, home care workers do so under vastly different social and economic circumstances. When a client dies, home care workers often lose both a close relationship and a job. Though research suggests that health care workers' grief may frequently be disenfranchised, there is no in-depth study of the mechanisms that disenfranchise home care workers' grief specifically. To address this gap, our study used focus groups and peer interviews between home care workers in New York City. We describe four interrelated grief strategies they employ to navigate social and employer-based "grieving rules." Our findings suggest that home care workers' grief is disenfranchised via employer and societal underestimations of their relationships with clients and their losses when clients die, particularly job loss. Building on our findings, we suggest alterations to agency practices and home care systems to improve support for workers.

Validity and reliability of the Palliative Care Transition Measure for Caregivers (PCTM-C)

OBJECTIVE

Patients suffering from advanced disease face different care transitions. The transition from acute to palliative care is challenging and may lead to the discontinuity of care. Family caregivers become important sources of information, as patients begin to experience difficulties in coping with emotional transition events. The Care Transition Measure was developed to evaluate care transitions as experienced by the elderly. It has never been used in palliative care. The aim of this study was to test the validity and reliability of a modified version of the Palliative Care Transition Measure, specifically the Palliative Care Transition Measure for Caregivers (PCTM-C).

METHOD

The study included two main phases. Phase I focused on the construction of a modified version of the Palliative Care Transition Measure through two focus groups and by computing the content validity index. Phase II focused on testing the psychometric properties of the PCTM-C on 272 family caregivers through confirmatory factor analysis.

RESULT

The content validity index for each of the items was higher than 0.80, whereas that for the scale was 0.95. The model tested with confirmatory factor analysis fitted the data well and confirmed that the transition measures referred to communication, integrated care and a trusting-relationship, and therefore the core dimensions of continuity according to existing conceptual models. The internal consistency was high (Cronbach's alpha = 0.94).

SIGNIFICANCE OF RESULTS

The PCTM-C proved to be a suitable measure of the quality of such transitions. It may be used in clinical practice as a continuity quality indicator and has the potential to guide interventions to enhance family caregivers' experience of care continuity.

"I Can Never Be Too Comfortable": Race, Gender, and Emotion at the Hospital Bedside

In this article, we examine how race and gender shape nurses' emotion practice. Based on audio diaries collected from 48 nurses within two Midwestern hospital systems in the United States, we illustrate the disproportionate emotional labor that emerges among women nurses of color in the white institutional space of American health care. In this environment, women of color experience an emotional double shift as a result of negotiating patient, coworker, and supervisor interactions. In confronting racist encounters, nurses of color in our sample experience additional job-related stress, must perform disproportionate amounts of emotional labor, and experience depleted emotional resources that negatively influence patient care. Methodologically, the study extends prior research by using audio diaries collected from a racially diverse sample to capture emotion as a situationally emergent and complex feature of nursing practice. We also extend research on nursing by tracing both the sources and consequences of unequal emotion practices for nurse well-being and patient care.

The Emotional Labor of Personal Grief in Palliative Care: Balancing Caring and Professional Identities

The paid provision of care for dying persons and their families blends commodified emotion work and attachments to two often-conflicting role identities: the caring person and the professional. We explore how health care employees interpret personal grief related to patient death, drawing on interviews with 12 health care aides and 13 nurses. Data were analyzed collaboratively using an interpretively embedded thematic coding approach and constant comparison. Participant accounts of preventing, postponing, suppressing, and coping with grief revealed implicit meanings about the nature of grief and the appropriateness of grief display. Employees often struggled to find the time and space to deal with grief, and faced normative constraints on grief expression at work. Findings illustrate the complex ways health care employees negotiate and maintain both caring and professional identities in the context of cultural and material constraints. Implications of emotional labor for discourse and practice in health care settings are discussed.

Nurses’ moral experiences of assisted death: A meta-synthesis of qualitative research

Background:

Legislative changes are resulting in assisted death as an option for people at the end of life. Although nurses’ experiences and perspectives are underrepresented within broader ethical discourses about assisted death, there is a small but significant body of literature examining nurses’ experiences of caring for people who request this option.

Aim:

To synthesize what has been learned about nurses’ experiences of caring for patients who request assisted death and to highlight what is morally at stake for nurses who undertake this type of care.

Design:

Qualitative meta-synthesis.

Methods:

Six databases were searched: CINAHL, Medline, EMBASE, Joanna Briggs Institute, PsycINFO, and Web of Science. The search was completed on 22 October 2014 and updated in February 2016. Of 879 articles identified from the database searches, 16 articles were deemed relevant based on inclusion criteria. Following quality appraisal, 14 studies were retained for analysis and synthesis.

Results:

The moral experience of the nurse is (1) defined by a profound sense of responsibility, (2) shaped by contextual forces that nurses navigate in everyday end-of-life care practice, and (3) sustained by intra-team moral and emotional support.

Discussion:

The findings of this synthesis support the view that nurses are moral agents who are deeply invested in the moral integrity of end-of-life care involving assisted death. The findings further demonstrate that to fully appreciate the ethics of assisted death from a nursing standpoint, it is necessary to understand the broader constraints on nurses’ moral agency that operate in everyday end-of-life care.

Ethical considerations:

Research ethics board approval was not required for this synthesis of previously published literature.

Conclusion:

In order to understand how to enact ethical practice in the area of assisted death, the moral experiences of nurses should be investigated and foregrounded.

Nursing futility, managing medicine: Nurses’ perspectives on the transition from life-prolonging to palliative care

The shift from life-prolonging and palliative care can be fraught with interpersonal complexities as patients face dilemmas around mortality and the dying process. Nurses can play a central role in managing these moments, often with a focus on promoting and enhancing communication around: the meaning of palliative care, the nature of futility and the dying process more broadly. These sites of nurse–patient communication can be highly charged and pose unique challenges to nurses including how to balance nursing perspectives versus those of other stakeholders including doctors. Here, drawing on interviews with nurses, we explore their accounts of communication about futility and the process of transitioning to palliative care. The interviews reveal nurses’ perspectives on the following: the art of conversing around futility and managing patient resistance, the influence of guilt and individual biographies in shaping communication, the importance of non-verbal and the informal in communication, the impact of conflicting organisational expectations on nurses and the process of learning to effectively communicate. We argue that these transitional moments articulate important, and at times problematic, aspects of contemporary nursing and nurse–medical relations.

Hospice nurses' emotional challenges in their encounters with the dying

The purpose of this study was to explore nurses’ emotional challenges when caring for the dying in hospices. The study has a qualitative design, and knowledge was developed through a dialectical exchange between theory and data. Ten individual in-depth interviews were conducted with nurses recruited from two hospices in Denmark. Although all of the nurses said that they experienced emotional challenges or felt emotionally touched during their work, the study found a variety of opinions related to the extent to which their emotional reactions should be revealed in their role as a hospice professional. The participants described their emotional challenges as being simultaneously draining and enriching experiences leading to personal and professional growth and development. The study may contribute to increased awareness of emotional challenges for hospice nurses, which involve continuous reflection and balancing between meeting the dying as a human being and meeting the dying as a hospice professional.

The role and significance of nurses in managing transitions to palliative care: a qualitative study

OBJECTIVES

Nurses are generally present, and often influential, in supporting patient and family acceptance of medical futility and in assisting doctors in negotiating referral to palliative care. Yet the specificities of the nursing role and how nurses may contribute to timely and effective referrals is not well understood. This study aimed to systematically explore hospital-based nurses' accounts of the transition to palliative care, and the potential role of nurses in facilitating more effective palliative care transitions.

DESIGN

Qualitative study using semistructured interviews.

SETTING

Two health services with public as well as private clinical environments in a major metropolitan area of Australia.

PARTICIPANTS

Hospital-based nurses (n=20) who regularly work with patients at the point of referral and in managing transitions to palliative care.

RESULTS

Four significant themes emerged from thematic analysis. These include: (1) professional dynamics and the roles played by nurses in initiating the transition to palliative care; (2) the value of nurses' informal interactions in timely and effective transitions; (3) the emerging challenge of managing task-oriented nursing versus intense emotional nursing work at the point of medical futility and (4) the emotional burden experienced by nurses within this clinical context. Nurses self-reported occupying critical albeit complex roles in the management of medical futility and the transition to palliative care. They reported experiencing significant emotional burden in balancing interpersonal and interprofessional relationships during this time.

CONCLUSIONS

The results suggest that nurses may be utilised in a more formalised and systematic fashion in the context of managing medical futility and the need to topicalise the transition, with the focus shifted away from medical referrals towards more team-based and patient-centred timely transitions. Further research focused on the experiences of doctors, allied health professionals, patients and families is required to provide a broader interdisciplinary understanding of futility and contributions to the negotiation of palliative care.