The transition experience of rural older persons with advanced cancer and their families: a grounded theory study

Improving Transitions in Care for Patients and Family Caregivers Living in Rural and Underserved Areas: The Caregiver Advise, Record, Enable (CARE) Act

In this Perspective, we contend bold action is needed to improve transitions from hospitals to home for aging patients and their family caregivers living in rural and underserved areas. The Caregiver Advise, Record, Enable (CARE) Act, passed in over 40 US states, is intended to provide family caregivers of hospitalized patients with the knowledge and skills needed for safe and efficient transitions. It has broken important ground for family caregivers who assist with transitions in patient care. It may fall short, however, in addressing the unique needs of family caregivers living in rural and underserved areas. We contend that to realize the intended safety, cost, and care quality benefits of the CARE Act, especially for those living in rural and underserved areas, states need to expand the Act's scope. We provide three recommendations: 1) modify hospital information systems to support the care provided by family caregivers; 2) require assessments of family caregivers that reflect the challenges of family caregiving in rural and underserved areas; and 3) identify local resources to improve discharge planning. We describe the rationale for each recommendation and the potential ways that an expanded CARE Act could reduce the risks associated with transitions in care for aging patients.

A qualitative study on redefining normality in relatives of patients with advanced cancer

OBJECTIVE

To obtain insight into adaptation processes of redefining normality and its influencing factors in relatives of patients with advanced cancer.

METHODS

An exploratory qualitative study among relatives of patients with advanced cancer was conducted. Participants were purposively recruited. Ten in-depth individual (relative only) and 16 dyad (relative and patient together) interviews were conducted, transcribed verbatim, and analyzed by means of thematic analysis, drawing on elements of grounded theory, combining both inductive and deductive elements.

RESULTS

Two adaptation processes of (redefining) normality were identified: assimilation and accommodation. The latter was found to be the main way of adapting to new events. Assimilative coping strategies entailed "continuing to do the same activities as done before the disease," "difficulty accepting the situation," "avoiding to think about the disease," and "living in the short term." Accommodative strategies involved "arranging practical matters," "thinking about the future," "doing what is feasible," "engaging in new activities," "accepting the situation," "seeking distraction," "living in the short term," and "focusing on what truly matters in life." The interplay between the diagnosis and treatment of cancer, a deteriorating disease status, and the accompanying uncertainty about the future was of influence on the relatives' coping strategies.

CONCLUSION

When the new situation is too divergent to assimilate, accommodation may be necessary for relatives to cope with the growing complexity of the consequences of their loved one's illness. Accommodative coping then involves accepting the changing reality and actively making the necessary adjustments to build resilience and cope with the new circumstances.

Implementing the European code of cancer practice in rural settings

Existing evidence often indicates higher cancer incidence and mortality rates, later diagnosis, lower screening uptake and poorer long-term survival for people living in rural compared to more urbanised areas. Despite wide inequities and variation in cancer care and outcomes across Europe, much of the scientific literature explicitly exploring the impact of rurality on cancer continues to come from Australia and North America. The European Code of Cancer Practice or "The Code" is a citizen and patient-centred statement of the most salient requirements for good clinical cancer practice and has been extensively co-produced by cancer patients, cancer professionals and patient advocates. It contains 10 key overarching Rights that a cancer patient should expect from their healthcare system, regardless of where they live and has been strongly endorsed by professional and patient cancer organisations as well as the European Commission. In this article, we use these 10 fundamental Rights as a framework to argue that (i) the issues and needs identified in The Code are generally more profound for rural people with cancer; (ii) addressing these issues is also more challenging in rural contexts; (iii) interventions and support must explicitly account for the unique needs of rural residents living with and affected by cancer and (iv) new innovative approaches are urgently required to successfully overcome the challenges faced by rural people with cancer and their caregivers. Despite equitable healthcare being a key European policy focus, the needs of rural people living with cancer have largely been neglected.

Older persons' perceptions and experiences of community palliative care: a systematic review of qualitative evidence

OBJECTIVE

The objective of this review was to critically appraise and synthesize qualitative evidence of older persons' perceptions and experiences of community palliative care.

INTRODUCTION

Palliative care focuses on the relief of symptoms and suffering at the end of life and is needed by approximately 56.8 million people globally each year. An increase in aging populations coupled with the desire to die at home highlights the growing demand for community palliative care. This review provides an understanding of the unique experiences and perceptions of older adults receiving community palliative care.

INCLUSION CRITERIA

This review appraised qualitative studies examining the perceptions and experiences of older adults (65 years or older) receiving community palliative care. Eligible research designs included, but were not limited to, ethnography, grounded theory, and phenomenology.

METHODS

A search of the literature across CINAHL (EBSCOhost), MEDLINE (Ovid), Embase (Ovid SP), Web of Science Core Collection, and Scopus databases was undertaken in July 2021 and updated November 1, 2022. Included studies were published in English between 2000 and 2022. The search for unpublished studies included ProQuest Dissertations and Theses. Study selection, quality appraisal, and data extraction were performed by 2 independent reviewers. Findings from the included studies were pooled using the JBI meta-aggregation method.

RESULTS

Nine qualitative studies involving 98 participants were included in this review. A total of 100 findings were extracted and grouped into 14 categories. Four synthesized findings evolved from these categories: i) Older persons receiving palliative care in the community recognize that their life is changed and come to terms with their situation, redefining what is normal, appreciating life lived, and celebrating the life they still have by living one day at a time; ii) Older persons receiving palliative care in the community experience isolation and loneliness exacerbated by their detachment and withdrawal from and by others; iii) Older persons receiving palliative care in the community face major challenges managing prevailing symptoms, medication management difficulties, and costs of medical care and equipment; and iv) Older persons want to receive palliative care and to die at home; however, this requires both informal and formal supports, including continuity of care, good communication, and positive relationships with health care providers.

CONCLUSIONS

Experiences and perceptions of community palliative care vary among older adults. These are influenced by the individual's expectations and needs, available services, and cost. Older adults' input into decision-making about their care is fundamental to their needs being met and is contingent on effective communication between the patient, family, and staff across services. Policy that advocates for trained palliative care staff to provide care is necessary to optimize care outcomes, while collaboration between staff and services is critical to enabling holistic care, managing symptoms, and providing compassionate care and support.

Understanding what affects psychological morbidity in informal carers when providing care at home for patients at the end of life: a systematic qualitative evidence synthesis

Background

Informal carers are central in supporting patients at the end of life, but this has substantial negative impacts on carers' own mental health. When carers are unable to cope, this may affect their ability to support the patient and increase the likelihood of patient hospital admissions. Further, demographic changes mean demands for care at and before end of life are increasing and existing services will struggle to meet these demands. It is important to recognise carers as a vital resource and prevent adverse health outcomes from caregiving (and thereby limit their consequences). Large individual variation in the level of psychological morbidity from end-of-life caregiving suggests there is scope for interventions to improve carer mental health if we can understand the underlying factors.

Objectives

This meta-synthesis of qualitative studies aims to identify factors reported by carers as important to their mental health.

Data sources

Searches of MEDLINE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Social Science Citation Index, EMBASE, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, and Cochrane Qualitative Reviews 1 January 2009 to 24 November 2019 for empirical publications from Organization for Economic Cooperation and Development countries in English/Scandinavian on factors affecting adult carer mental health during end-of-life caregiving in home settings.

Review methods

Systematic qualitative meta-synthesis in collaboration with a Public Patient Involvement carer Review Advisory Panel, included thematic synthesis, followed by a best-fit framework synthesis, informed by principles of meta-ethnography. Critical Appraisal Skills Programme Qualitative Studies Checklist was used.

Results

Thirty-three eligible studies identified six themes encompassing factors perceived by carers to affect their mental health during end-of-life caregiving. These were: (1) the patient condition (including patient decline); (2) impact of caring responsibilities (including exhaustion, lack of time for own needs, isolation); (3) relationships (including quality of the patient-carer relationship); (4) finances (including financial concerns, impact on work); (5) carers' internal processes (including loss of autonomy, lack of confidence, coping strategies); and (6) support (including lack of informal support, inadequacies in formal support information and care provision, limited collaboration, disjointed care). Reported strategies to improve mental health were linked to the final two themes, with suggestions on how to manage carers' internal processes and build appropriate support. Findings correspond with literature 1998-2008, indicating consistency in factors affecting carers and adding validity to findings.

Limitations

The review was limited to caregiving in the home setting and studies from Organization for Economic Cooperation and Development countries published in English and Scandinavian. Identified papers predominantly considered carers of people with cancer, with little research into ethnic-minority perspectives. The review may therefore not fully encompass factors affecting carers of people with longer-term conditions, or those within other care settings, countries and population groups.

Conclusions and future work

A wide range of both internal and contextual factors may lead to psychological morbidity when caring for someone at the end of life. Future work within practice therefore requires a broad-based rather than narrow approach to sustaining and improving carer mental health. Future work within research requires collaboration between researchers and stakeholders within policy, commissioning, practice and carer organisations to develop solutions and assess their effectiveness. Further, researchers need to develop better models for factors affecting carer mental health and their interaction, to build a stronger evidence base and better guide interventions.

Study registration

This study is registered as PROSPERO CRD42019130279.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number HSDR 18/01/01 and will be published in full in Health and Social Care Delivery Research. See the NIHR Journals Library website for further project information.

Exploring the Relationship Between Health-Illness Transition Experiences and Distress Among Patients With Pancreatic Cancer

OBJECTIVES

To explore the correlation between health-illness transition (HIT) experiences and distress among patients with pancreatic cancer.

SAMPLE & SETTING

55 patients with a diagnosis of pancreatic cancer receiving chemotherapy at a tertiary cancer center in New York.

METHODS & VARIABLES

A prospective correlational study was performed to explore the frequency, extent, and management of HITs. HITs were evaluated using the Measurement of Transitions in Cancer Scale, and distress was measured with the National Comprehensive Cancer Network Distress Thermometer.

RESULTS

All patients experienced at least one HIT. The extent of HITs decreased over time. Patients reported that they managed HITs moderately well. There was a significant correlation between unmanaged HITs and distress. As distress increased, the extent of the physical and emotional HITs increased and management worsened.

IMPLICATIONS FOR NURSING

HITs are ubiquitous among patients diagnosed with pancreatic cancer. Associated distress inhibits management. Nurses are well suited to assess for potential HITs and to support self-management of HITs.

Meanings and Experiences of End-of-Life Patients and Their Family Caregivers in Hospital-to-Home Transitions: A Constructivist Grounded Theory Study

This study explored the meanings and experiences of patients with terminal chronic diseases and their caregivers, who face the imminence of death in the home environment after hospital discharge. The qualitative study used constructivist grounded theory. The participants were individuals with a terminal chronic illness, discharged to home, and their family caregivers. Data were gathered from in-depth interviews and field notes, and a comparative analysis was conducted to identify categories and codes, according to Charmaz's theory. The sample consisted of 21 participants. Three inter-related data categories emerged: "Floating between acceptance and resistance: Perceiving the proximity of death", "Analysing the end from other perspectives: it is in the encounter with death that life is understood" and "Accepting the path: between the love of letting go and the love of wanting to stay". The categories translate the reconstruction of those facing end-of-life occurring in the home environment. It is amid the imminence of death that life gains intensity and talking about the finitude of life configures an opportunity to see life from other perspectives. Giving voice to individuals facing the mishaps of a terminal illness fosters the path to a comfortable death. For health professionals, it is an opportunity to provide structured and humanized care with an ethical attitude, in defence of human dignity.

Factors related to satisfaction of cancer patients with transfer arrangements made by university hospitals at the end-of-life in Japan: a cross-sectional questionnaire survey of bereaved family members

PURPOSE

Cancer patients in university hospitals often face a difficult decision regarding transfer to other care settings at the end-of-life. Arrangements for a satisfying transfer are important for reducing the psychosocial impact of the transition, but few studies have evaluated this aspect. This study aimed to identify factors related to the satisfying arrangement of transfers to other care settings from university hospitals.

METHODS

A total of 400 bereaved family members of cancer patients in Japan participated in this cross-sectional web-based questionnaire survey. Statistical methods including decision tree analysis were conducted to identify factors significantly associated with satisfying transfer arrangements.

RESULTS

More than 60% of cancer patients were satisfied with the transfer arrangements made by university hospitals. Decision tree analysis revealed that the factor most significantly associated with satisfaction with transfer arrangements was "satisfaction with contents of the explanation about transfer." The following significant factors were also extracted: "timing of being informed of transfer," "presence of primary care physician," and "presence of trustworthy staff." "Satisfaction with overall care from university hospital staff" and "involvement of palliative care team" were identified as factors contributing to a high degree of satisfaction with transfer arrangements.

CONCLUSION

In order to make satisfying transfer arrangements from university hospitals for cancer patients at the end-of-life, healthcare professionals should provide satisfactory explanations about the transfer process in order to meet the information needs of patients. To be effective, healthcare professionals should initiate transfer arrangements prior to cancer treatment, while simultaneously building trusting relationships with patients.

A mixed-method evaluation of a volunteer navigation intervention for older persons living with chronic illness (Nav-CARE): findings from a knowledge translation study

Background

Volunteer navigation is an innovative way to help older persons get connected to resources in their community that they may not know about or have difficulty accessing. Nav-CARE is an intervention in which volunteers, who are trained in navigation, provide services for older persons living at home with chronic illness to improve their quality of life. The goal of this study was to evaluate the impact of Nav-CARE on volunteers, older persons, and family participating across eight Canadian sites.

Methods

Nav-CARE was implemented using a knowledge translation approach in eight sites using a 12- or 18-month intervention period. A mixed method evaluation was used to understand the outcomes upon older person engagement; volunteer self-efficacy; and older person, family, and volunteer quality of life and satisfaction with the intervention.

Results

Older persons and family were highly satisfied with the intervention, citing benefits of social connection and support, help with negotiating the social aspects of healthcare, access to cost-effective resources, and family respite. They were less satisfied with the practical help available for transportation and errands. Older persons self-reported knowledge of the services available to them and confidence in making decisions about their healthcare showed statistically significant improvements (P < .05) over 12–18 months. Volunteers reported satisfaction with their role, particularly as it related to building relationships over time, and good self-efficacy. Volunteer attrition was a result of not recruiting older persons in a timely manner. There was no statistically significant improvement in quality of life for older persons, family or volunteers from baseline to study completion.

Conclusions

Findings from this study support a developing body of evidence showing the contributions volunteers make to enhanced older person and family well-being in the context of chronic illness. Statistically significant improvements were documented in aspects of client engagement. However, there were no statistically significant improvements in quality of life scores even though qualitative data illustrated very specific positive outcomes of the intervention. Similar findings in other volunteer-led intervention studies raise the question of whether there is a need for targeted volunteer-sensitive outcome measures.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s12904-020-00666-2.

Understanding Symptom Burden in Patients With Advanced Cancer Living in Rural Areas

OBJECTIVES

To evaluate the feasibility of using a biobehavioral approach to examine symptom burden in rural residents with advanced cancer.

SAMPLE & SETTING

21 patients with advanced lung, colorectal, or pancreatic cancer were enrolled at the University of Iowa in Iowa City.

METHODS & VARIABLES

Using Cleeland's cytokine-immunologic model of symptom expression, symptom burden (i.e., severity, count, and interference) and inflammatory cytokines were measured for 24 weeks. Potential predictors included demographics, clinical characteristics, optimism, social support, and cancer-related stress. Descriptive statistics, Wilcoxon rank-sum, and Fisher's exact test were used for analysis.

RESULTS

Recruitment and retention rates were similar for rural and nonrural patients. Demographics, optimism, and social support were no different between groups. The cancer-related stress total score for rural patients was nearly half of the score of nonrural patients, with rural patients reporting significantly less avoidance. Symptom severity for the five worst symptoms remained moderate during the 24 weeks, whereas nonrural residents reported steady declines in severity of their five worst symptoms. Significant differences in inflammatory cytokines between groups were only found at one time point.

IMPLICATIONS FOR NURSING

Rural residents who seek care at a cancer center may be clinically and demographically more similar to their nonrural counterparts than to rural residents seeking local care.

Hope to hope: Experiences of older people with cancer in diverse settings

PURPOSE

The purpose of the study was to explore experiences of older people with cancer in ascertaining the attributes of a person-centred approach in sustaining hope and enabling human flourishing. This was a qualitative study comparing patients and professional experiences and perceptions of care across to ward settings.

METHODS

Methods involved 10 semi-structured interviews conducted with patients and focus groups (n = 6) and 10 semi-structured interviews with health professionals. Three dissemination focus groups (n = 14) were also carried out with professionals to allow further analysis of the data.

RESULTS

Two main themes were identified, including 'Emotional adaptations of hope: wants and expectations' and 'Hope through belittling their illness'. Findings highlight the way hope is conveyed and the emphasis' accorded to issues such as societal perceptions, knowledge, expectations of care, life stage, relationships, identity, and emotions. Findings also reinforce the importance of maintaining hope, recognising the different ways hope is used, and enabling patients to flourish.

CONCLUSION

This study highlights how hope is facilitated through the interaction between patients and professionals and that the relational interactive stance. This current study establishes that hope seemed to be temporal, contextual and dynamic in nature, involving an ongoing process. Helping older people with cancer to understand their illness considering the situation of lives and experiences is essential to address expectations and wants.

Metasynthesis: Dying adults' transition process from cure-focused to comfort-focused care

AIM

To describe and explain the process of transition from cure-focused to comfort-focused health care as perceived and reported by patients, family members, and healthcare providers.

BACKGROUND

Moving into the last phase of life due to advanced illness constitutes a developmental transition with increased vulnerability for patients and family.

DESIGN

Qualitative metasynthesis.

DATA SOURCES

Medline, CINAHL, and PsycInfo databases searched from inception through March 2016. Primary research reports published from 1990 to 2015, using qualitative designs to report transition experiences of patients, family members, and/or healthcare providers were included.

REVIEW METHODS

Key elements were extracted and organized into matrices. Findings from each report were analysed using qualitative coding.

RESULTS

The sample was 56 unique reports from 50 primary studies. Patients and families emphasized the importance of receiving understandable information, emotional support, respect for personhood and control. The critical juncture of 'realizing terminality' preceded a transition to comfort-focused care. Subsequently, a shift in goals of care emphasizing comfort and quality of life could occur. Continued provision of information, effective support, respect and control promoted 'reframing perceptions' and capacity to embrace a changed identity. Reframing allowed patient and family to find meaning and value in this last phase of life and to embrace the opportunity to prepare for death, nurture relationships, and focus on quality of living.

CONCLUSION

Understanding the developmental process that can be engaged by patients and families at the end of life provides a theoretical basis that can inform choice and timing of interventions to reduce suffering and enhance positive outcomes.

How family caregivers help older relatives navigate statutory services at the end of life: A descriptive qualitative study

Background:

A key challenge in meeting the palliative care needs of people in advanced age is the multiple healthcare and social service agencies typically involved in their care. The ‘patient navigator’ model, originally developed in cancer care, is the professional solution most often recommended to address this challenge. However, little attention has been paid, or is known, about the role that family carers play in enabling their dying relatives to negotiate service gaps.

Aim:

To explore the role family caregivers play in helping people dying in advanced old age navigate health services at the end of life.

Design:

Qualitative study using semi-structured interviews and analysed via thematic analysis.

Setting/participants:

A total of 58 interviews were conducted in New Zealand with the family caregivers of 52 deceased older relatives who had been participants in Life and Living in Advanced Age: a Cohort Study in New Zealand.

Results:

Fragmentation of services was the key concern, causing distress both for the older person and their family caregivers. Carers identified and engaged with appropriate services in order to facilitate care and treatment. Their involvement was not always met by healthcare professionals with respect or regard to their knowledge of the older person’s needs.

Conclusion:

Family caregivers are trying to help their older relatives overcome the limitations of fragmented health systems at the end of life. They are doing so at times by stepping in to perform patient navigator tasks usually conceptualised as a role for statutory services to carry out. Programmes and services need to be implemented that will better support family carers who are acting as care navigators.

Transitions as experienced by persons in palliative care circumstances and their families - a qualitative meta-synthesis

Background

When receiving palliative care, patients and their families experience altered life situations in which they must negotiate challenges in daily life, increased care and new roles. With limited time, they also experience emotional changes that relate to their uncertain future. Transitions experienced in such situations are often studied by focusing on individual aspects, which are synthesized in the following study. The aim was to conduct a qualitative meta-synthesis to explore the experiences patients and their families gain during transitions in palliative care circumstances.

Methods

A qualitative meta-synthesis was conducted following an inductive approach as proposed by Sandelowski and Barroso. Inclusion criteria were studies with adult persons in palliative situations and articles published in English or German. Relevant articles were identified by researching the Pubmed and Cinahl databases, as well as by hand searches in journals and reference lists for the period 2000–2015. The findings of each study were analyzed using initial coding, followed by axial and selective coding in this order. Consequently, a conceptual model was derived from the categories.

Results

In total 2225 articles were identified in the literature search. Finally, 14 studies were included after the selection process. The central phenomenon observed among palliative care patients and their families was maintaining normality during transitions. Transitions are initially experienced unconsciously until a crisis occurs and responsive actions are necessary, which encourages patients and families to perceive the situation consciously and develop strategies for its negotiation. Patients remain caught between hopelessness and valuing their remaining time alive. As the illness progresses, informal caregivers reprioritize and balance their roles, and after death, family members inevitably find themselves in changed roles.

Conclusions

In palliative care situations, transitions are experienced differently by patients and their families in a constant phenomenon that oscillates between unconscious and conscious perceptions of transitions. The derived conceptual model offers an additional perspective to existing models and helps to clarify the phenomenon in practical settings. The study promotes a differentiated conceptual view of transitions and emphasizes patients’ and families’ perspectives.

Education, Training, and Mentorship of Caregivers of Canadians Experiencing a Life-Limiting Illness

BACKGROUND

Research suggests that caregiver preparedness is essential to minimizing the negative impacts of caregiving. Not being prepared is associated with fear, anxiety, stress, and feelings of insufficiency/uncertainty specific to the caregiver role.

OBJECTIVE

To determine what resources are required to ensure adequate education, training, and mentorship for caregivers of Canadians experiencing a life-limiting illness.

DESIGN

Informed by the Ispos Reid survey, the methods for this article involved a rapid literature review that addressed caregiver experiences, needs and issues as they related to health, quality of life, and well-being.

RESULTS

Given the burden of care, caregiver education, training, and mentorship are suggested to be best met through the palliative navigator model, wherein the patient-caregiver dyad is recognized as an integrated unit of care.

CONCLUSIONS

The palliative navigator approach is a key role in the education, training, and mentorship of caregivers.

Rural end-of-life care from the experiences and perspectives of patients and family caregivers: A systematic literature review

BACKGROUND

End-of-life care must be relevant to the dying person and their family caregiver regardless of where they live. Rural areas are distinct and need special consideration. Gaining end-of-life care experiences and perspectives of rural patients and their family caregivers is needed to ensure optimal rural care.

AIMS

To describe end-of-life care experiences and perspectives of rural patients and their family caregivers, to identify facilitators and barriers to receiving end-of-life care in rural/remote settings and to describe the influence of rural place and culture on end-of-life care experiences.

DESIGN

A systematic literature review utilising the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

Four databases (PubMed, CINAHL, Scopus and Web of Science) were searched in January 2016, using a date filter of January 2006 through January 2016; handsearching of included article references and six relevant journals; one author contacted; pre-defined search terms and inclusion criteria; and quality assessment by at least two authors.

RESULTS

A total of 27 articles (22 rural/remote studies) from developed and developing countries were included, reporting rural end-of-life care experiences and perspectives of patients and family caregivers. Greatest needs were informational (developed countries) and medications (developing countries). Influence of rural location included distances, inaccessibility to end-of-life care services, strong community support and importance of home and 'country'.

CONCLUSION

Articulation of the rural voice is increasing; however, there still remain limited published rural studies reporting on patient and family caregivers' experiences and perspectives on rural end-of-life care. Further research is encouraged, especially through national and international collaborative work.

A metasynthesis study of family caregivers' transition experiences caring for community-dwelling persons with advanced cancer at the end of life

BACKGROUND

Family caregivers (broadly defined as family and friends) experience multiple concurrent transitions when caring for a person with advanced cancer.

AIMS

To (a) explore the transition experience of family caregivers caring for persons with advanced cancer living in the community, (b) describe potential triggers for transitions, (c) identify what influences this experience, and (d) develop a conceptual framework of their transition experience.

DESIGN

Sandelowski and Barroso's methodology for synthesizing qualitative research included (a) a comprehensive search of empirical literature, (b) quality appraisal of qualitative studies, (c) classification of studies, and (d) synthesis of the findings.

DATA SOURCES

Literature was sourced from six electronic data bases. Inclusion criteria were as follows: (a) published qualitative studies (and mixed-method designs) of the caregiving experience of family caregivers of community-living persons with advanced cancer at the end of life, (b) participants (caregivers and care recipients) of 18 years of age and above, (c) studies published in English in any country, and (d) studies published between 2004 and 2014.

RESULTS

A total of 72 studies were included in the metasynthesis. Family caregivers experience a "life transition" whereby their lives are permanently altered. The participants described the process of redefining normal which consisted of coming to terms with their situation and connecting with others. Outcomes of these processes were as follows: (a) maintaining a sense of personhood, (b) reframing hope, (c) maintaining self-efficacy, (d) finding meaning, and (e) preparing for the death of their care recipient.

CONCLUSION

The findings provide a framework to guide the development of supportive programs and future research.

Bereaved family members' perspectives on suffering among older rural cancer patients in palliative home nursing care: A qualitative study

Little is known about experiences with receiving home nursing care when old, living in a rural area, and suffering from end-stage cancer. The aim of this study was thus to investigate bereaved family members' perceptions of suffering by their older relatives when receiving palliative home nursing care. Qualitative semi-structured interviews were conducted with 10 family members, in Norway during autumn 2015, and directed content analysis guided by Katie Eriksson's theoretical framework on human suffering was performed upon the data. The two main categories identified reflected expressions of both suffering and well-being. Expressions of suffering were related to illness, to care and to life and supported the theory. Expressions of well-being were related to other people (e.g. familiar people and nurses), to home and to activity. The results indicate a need to review and possibly expand the perspective of what should motivate care. Nursing and palliative care that become purely disease and symptom-focused may end up with giving up and divert the attention to social and cultural factors that may contribute to well-being when cure is not the goal.

'All I can do is help': Transition experiences of male spouse caregivers of women with breast cancer

The transition experience of male spouses of women with breast cancer is largely unknown. Ninety-one open-ended surveys of male spouses were analyzed using thematic analysis to understand the transition experience of this population when their partners were diagnosed and treated for breast cancer. While 10 participants indicated they experienced no changes, the majority experienced changes to their roles and relationships, their mental health, and their share of household work. Spouses took on a supportive role. They adjusted to the changes they faced by proactively becoming aware of their situation, fostering a positive approach, and being actively involved in their partners' experiences. Implications for nurses entail recognizing the role of the spouse, as well as facilitating access to reliable information and support networks.

Composing hope through collage: A community-based intervention for cancer survivors living with lymphedema

Secondary lymphedema after cancer may result in distress, yet few interventions exist to support coping skills in this population. As part of a community-based intervention, we piloted the use of creative practices to promote active orientations to hope. A total of 19 participants completed the workshops; 11 collaged. The main themes address the collage processes as well as their content. The former addresses sub-themes such as selecting/composing. The latter includes sub-themes related to movement depicted in the collages. Collages and their associated discussions concretized hoping as an active and accessible process for participants living with two chronic illnesses.

Developing Navigation Competencies to Care for Older Rural Adults with Advanced Illness

Navigators help rural older adults with advanced illness and their families connect to needed resources, information, and people to improve their quality of life. This article describes the process used to engage experts - in rural aging, rural palliative care, and navigation - as well as rural community stakeholders to develop a conceptual definition of navigation and delineate navigation competencies for the care of this population. A discussion paper on the important considerations for navigation in this population was developed followed by a four-phased Delphi process with 30 expert panel members. Study results culminated in five general navigation competencies for health care providers caring for older rural persons and their families at end of life: provide patient/family screening; advocate for the patient/family; facilitate community connections; coordinate access to services and resources; and promote active engagement. Specific competencies were also developed. These competencies provide the foundation for research and curriculum development in navigation.

Communicating during care transitions for older hip fracture patients: family caregiver and health care provider's perspectives

INTRODUCTION

Older hip fracture patients frequently require care across a variety of settings, from multiple individuals, including their family caregivers. We explored issues related to information sharing during transitional care for older hip fracture patients through the perspectives of both health care providers and family caregivers.

METHODS

Thirty-five semi-structured interviews were conducted with family caregivers (n = 9) and health care providers (n = 26) of six hip fracture patients to gather perspectives on information sharing at each care transition, beginning with post-surgical discharge from acute care. Data were analysed using conventional qualitative content analysis methods using NVivo8 software.

RESULTS

Both family caregivers and health care providers recognise that family caregivers' involvement has important benefits for patients, but this involvement is frequently limited by poor information sharing. Barriers include limited staff time, patient privacy regulations and lack of a clear structure to guide information sharing. Receiving, not offering, information was the focus of information sharing by both family caregivers and health care providers.

CONCLUSIONS

Specific barriers that lead to poor information sharing between family caregivers and health care providers have been identified in this study. Possible interventions to improve information sharing include encouraging communication with family caregivers as standard care practice, educational strategies and more effective use of health information systems and technologies.

Among neighbors: an ethnographic account of responsibilities in rural palliative care

OBJECTIVE

Building high quality palliative care in rural areas must take into account the cultural dimensions of the rural context. The purpose of this qualitative study was to conduct an exploration of rural palliative care, with a particular focus on the responsibilities that support good palliative care from rural participants' perspectives.

METHOD

This ethnographic study was conducted in four rural communities in Western Canada between June 2009 and September 2010. Data included 51 days of field work, 95 semistructured interviews, and 74 hours of direct participant observation. Thematic analysis was used to provide a descriptive account of rural palliative care responsibilities.

RESULTS

Findings focus on the complex web of responsibilities involving family, healthcare professionals, and administrators. Family practices of responsibility included provision of direct care, managing and coordinating care, and advocacy. Healthcare professional practices of responsibility consisted of interpreting their own competency in relation to palliative care, negotiating their role in relation to that interpretation, and individualizing care through a bureaucratic system. Administrators had three primary responsibilities in relation to palliative care delivery in their community: navigating the politics of palliative care, understanding the culture of the community, and communicating with the community.

SIGNIFICANCE OF RESULTS

Findings provide important insights into the complex ways rurality influences understandings of responsibility in palliative care. Families, healthcare providers, and administrators work together in fluid ways to support high quality palliative care in their communities. However, the very fluidity of these responsibilities can also work against high quality care, and are easily disrupted by healthcare changes. Proposed healthcare policy and practice changes, particularly those that originate from outside of the community, should undergo a careful analysis of their potential impact on the longstanding negotiated responsibilities.

Supporting rural family palliative caregivers

There is urgent need to effectively support the well-being of rural palliative family caregivers (FCGs). A mixed method study was conducted with 23 FCGs. Data collection included completion of an assessment questionnaire and semistructured interviews. The most prevalent needs identified by questionnaire were caring for the patient's pain, fatigue, body, and nourishment; FCG's fatigue and need for respite. Yet few FCGs wanted more attention to these needs by healthcare providers. FCGs resisted considering their own personal needs. Instead, they focused on needs related to providing care including to be(come) a palliative caregiver, be skilled and know more, navigate competing wishes, needs, demands, and priorities, and for "an extra pair of hands." Gaps in rural palliative services contributed to low expectations for assistance; reluctance to seek assistance was influenced by FCGs' resourcefulness and independence. Findings suggest that supporting FCGs will most likely be successful when framed in relation to their caregiving role.

A mixed methods study of hope, transitions, and quality of life in family caregivers of persons with Alzheimer's disease

BACKGROUND

Several research studies have reported the poor quality of life of family caregivers of persons with Alzheimer's disease (AD). However, factors that influence their quality of life have not been clearly defined. The purpose of this study was to examine factors associated with the quality of life of these caregivers such as demographic variables, their transition experience, and hope. A secondary aim was to explore the transition experience of family caregivers of persons with AD.

METHODS

A cross-sectional triangulation data transformation model mixed method design (Quant +Qual) was utilized to address the purpose of the study. Eighty family caregivers of persons with AD completed a survey with quantitative measures [demographic variables, Herth Hope Index (HHI-hope), World Health Organization Quality of Life -BREF (WHOQOL-BREF)] and a qualitative survey about their transitions experience. The qualitative data (transition open ended- survey) was converted to quantitative data using content analysis. Variables significant at the p < 0.10 level in the univariate analysis were entered in the multivariate generalized linear model used to determine significant factors associated with quality of life.

RESULTS

Subjects with higher hope scores (p < 0.0001) (Factor 1: temporality and future-cognitive-temporary dimension of hope) and who dealt with their transitions by actively seeking out knowledge and assistance (p = 0.02) had higher overall quality of life scores. HHI scores were associated with overall quality of life and for each of the four quality of life domains (physical psychosocial, relationships, and environment).

CONCLUSIONS

Hope played a significant role in the subjects' perceptions of overall quality of life as well as the 4 quality of life domains. This underscores the need to develop ways to foster hope in family caregivers. Moreover, the active engagement of families in seeking information and help, as a way to deal with their transitions, suggests encouraging this engagement is important. The findings of this study also suggest many directions for future research, such as increasing our understanding of the processes of transitions for this population.

Contribuições da literatura para a enfermagem de família no contexto rural

Trata-se de um estudo de revisão da literatura de enfermagem que objetivou identificar aspectos do ciclo vital e da saúde da família no contexto rural. Foram analisados 22 artigos, entre 2003 e 2010, obtidos nas bases Medline, Lilacs, BDEnf e Cinahl, selecionados sob critérios de inclusão e de exclusão. Os resultados mostram aspectos da saúde da unidade familiar nas transições típicas das fases do ciclo vital, a relação com os profissionais de enfermagem e implicações da informação/conhecimento de saúde nos comportamentos de cuidado e promoção da saúde familiar. Conclui-se que o cuidado da enfermagem promove a saúde das famílias rurais, ao considerar a cultura, a educação em saúde e o meio ambiente. Reforça a importância da informação e do conhecimento em saúde para a promoção de comportamentos saudáveis nas famílias, aliado ao papel da enfermagem no cuidado centrado na família, com ênfase na educação em saúde.

Decision making among older people with advanced heart failure as they transition to dependency and death

PURPOSE OF REVIEW

This review critically considers recent research, identifying patient experiences of, and preferences for, participation in decision making during the end-of-life transition.

RECENT FINDINGS

Clinicians typically experience significant difficulties in engaging older patients with advanced heart failure in discussions about palliative and end-of-life care and involving them in shared decision making. Advanced care planning is proposed as an approach to ensure greater patient involvement in end-of-life care management, although evidence regarding effective interventions in this area is limited. Policy initiatives and guidelines appear not to reflect clinical reality and healthcare professionals experience significant barriers in transferring the required knowledge and skills into their practice. The notion of transition itself as a process that healthcare professionals could use for assessment and management requires further research, but does offer more than just a focus on heart failure management at the end-of-life.

SUMMARY

This review indicates a need to think carefully about how policy recommendations and guidance relating to patient participation in decision making at the end-of-life can be effectively implemented in practice. The need for continuity of involvement from key health workers is identified as very important in this regard. 'Transition' is also considered as a concept that may offer health professionals a different approach for assessment and management of heart failure patients over a longer period and means of integrating heart failure management with palliative care.