Palliative care in the community: the challenge for district nurses

The development of a 7-day community specialist palliative care service

The author worked as a clinical nurse specialist (CNS) in community palliative care in the Central Lancashire area of England when the CNS service was extended to a 9am-to-5pm 7-day service. A project group was set up to canvas some of the key stakeholders for their views on the extension of the service. The group undertook a literature search, a telephone survey of services in other areas that were providing this level of service, and interviews to ascertain the views of district nurses in the locality of the proposed service extension. The extension of service has long been advocated and was one of the key recommendations in the UK Department of Health's peer-review process. Such an extension was implemented following the research phase and was then evaluated by the project lead and the community services manager. The extension was found to be effective in the ongoing monitoring and support of patients. Anecdotally, the CNS team also felt it had been proactive in preventing unnecessary hospital admissions, although this specific aspect is difficult to quantify. This article looks at how the service was developed, how it has evolved over time, and how it works today. Consideration is also given to benefits and limitations.

Connaissances et attitudes des infirmiers libéraux face à la douleur en fin de vie

BACKGROUND

Nurses play a crucial role in end-of-life care, especially for outpatients. It is important to assess their knowledge and attitudes regarding pain management during the end-of-life period.

METHODS

A random national sample of 602 French nurses providing home care responded to a telephone survey. The questionnaire included a scale of knowledge about pain and a short clinical case related to severe pain management, requiring WHO level 3 analgesia, for a dying patient.

RESULTS

The pain knowledge score depended on nurses' training and was higher for those living with another health professional. For the clinical case, only 60% of nurses favored the prescription of the analgesia recommended by international guidelines. This support depended on objective skills in pain management, but was less frequent for elderly or women patients.

DISCUSSION

Attitudes toward pain management at the end of life do not depend only on book learning. They are also influenced by more subjective factors that may cause inequality in care for women and the elderly. Nurse training programs should take such factors into account.

What do informal carers need from district nursing services?

More than 5 million informal carers provide support to individuals who wish to remain within their own homes. The role of informal carers in maintaining people within their own homes has been identified as crucial. This article considers the assessment of need of informal carers in the primary care setting, placing particular emphasis on the role of the district nurse as an advocate for informal carers when working with other health and social care service providers. Central to working with informal carers and acting as an advocate is communication, and unless informal carers feel that they are involved in the decision-making process, and listened to, they are unlikely to access appropriate support.

District nursing support for patients with cancer requiring palliative care

Patients with cancer spend the majority of the last year of life at home, with district nurses (DNs) as the main care coordinators and providers. However, there is a relative lack of empirical work on the DN role in this area. This study used qualitative, case-study methods to explore the role of district nurses caring for patients with cancer who require palliative care. The study focused on three patient cases and the researcher visited each patient with the DN on several occasions. The sample was three DNs and the principal data collection methods were episodes of participant observation (n=11) and in-depth interviews (n=12). The findings suggest that DN role was as linchpin or coordinator of palliative care at home. They were the main providers of physical and emotional support for the patients and families in this study. The supportive role of the DN involved referral to other agencies. Patient and carer preferences impacted on decision-making and care planning and reaching a compromise was often necessary.

Palliative care for breathless patients in the community

Breathlessness is one of the commonest symptoms experienced by people receiving palliative care. However, misunderstanding of the nature of palliative care may hinder assessment, management and evaluation of care and may contribute to the fear associated with living with breathlessness in the community. Knowledge of related anatomy and physiology of breathlessness is vital in informing nursing care and interventions. Pharmacological interventions have their place, but the focus of nursing care should be on systematic holistic assessment. Using this, nurses should adopt a proactive role in supporting and helping patients to adapt to change by maximizing coping strategies.

Caring for the terminally ill: the district nurse's perspective

This study aimed to explore the role of the district nurse in terminal care in order to understand and clarify the work that district nurses undertake in this area. District nurses view themselves as having a central and valued role in terminal care, yet studies have highlighted concerns that they may not have the necessary skills to provide effective terminal care. In order to target the educational and developmental needs of district nurses the role of the district nurse in terminal care was explored using a qualitative approach. Six semi-structured interviews, including the use of vignettes, were undertaken with district nurses from one community trust. Interviews were all taped and transcribed verbatim. Transcriptions were analysed using coding and categorizing with constant comparison of recurring themes. Common themes relating to how district nurses viewed their role in terminal care were then developed. The district nurses viewed their role as centring on the development of a relationship with the client and family. The relationship was a foundation to understanding and knowing the clients' and families' needs and was the medium through which all other care was given. The focus of care was determined by those needs identified through the relationship. Care needs identified within the study were complex and difficult to distinguish but fell within four themes: (1) emotional; (2) social; (3) physical; (4) informational. The importance of the relationship between the district nurse, the terminally ill client and the carer has not been clearly identified before and this study points towards the importance of formal structures to be put in place within palliative care and the provision of district nurse training to allow the opportunity and skills for this relationship to be fostered and developed.