Nurses and palliation in the community: the current discourse

A task service and a talking service: A qualitative exploration of bereaved family perceptions of community nursing care at the end of life

BACKGROUND

Greater emphasis on community-based care at the end of life is supported by the premise that most people want to be cared for and die at home. As such, it is important to understand the current state of palliative care nursing within an integrated generalist-specialist model of care in the community.

AIM

To explore bereaved family perceptions and experiences of community nursing at the end of life, with a particular focus on service integration.

DESIGN

A qualitative study design using semi-structured telephone interviews with bereaved family. A critical realist framework was used to inform the analysis of interview data and thematic analysis of data was used to identify key themes.

SETTING/PARTICIPANTS

Participants were the family carers of patients who had died within the catchment area of two large District Health Boards in Auckland, New Zealand.

RESULTS

Twenty-three participants were interviewed. Participants described their experiences of community nursing in terms of the service they provided. Hospice nursing roles were described in terms of a "talking service" and District Nursing as a "task service." There was minimal expectation of the general practice nurse in terms of palliative care support and little evidence of service integration.

CONCLUSION

Findings from this study support the need for a new integrated model of palliative care nursing which utilizes the unique skill set of nurses working across all community care settings including general practice, hospice and district nursing services. Accommodating different models of nursing care which can be responsive to patient need rather than limited to a defined service delivery model.

The role of healthcare support workers in providing palliative and end-of-life care in the community: a systematic literature review

Despite the widespread use of Health Care Support Workers (HCSWs) in providing palliative and end-of-life care, there is little information available about their contributions towards supporting patients who want to be cared for at home or to die at home. Between January and April 2011, a systematic review was conducted to address two questions: (i) What particular tasks/roles do HCSWs perform when caring for people at the end of life and their families to comply with their desire to remain at home?; (ii) What are the challenges and supporting factors that influence HCSWs' ability to provide palliative and end-of-life care in the community? Databases searched for relevant articles published between 1990 until April 2011 included CINAHL, EMBASE, PsychINFO, British Nursing Index, Web of Science, Medline and ASSIA. In total, 1695 papers were identified and their titles and abstracts were read. Ten papers met the eligibility criteria of the study. After the methodological quality of the studies was appraised, nine papers were included in the review. Judgements regarding eligibility and quality were undertaken independently by the authors. The findings indicate that HCSWs invest a great deal of their time on emotional and social support as well as on assisting in the provision of personal care. They are also involved in providing care for the dying, respite care for family members and offer domestic support. Although it is important to acknowledge the many positive aspects that HCSWs provide, the findings suggest three challenges in the HCSWs role: emotional attachment, role ambiguity and inadequate training. Support factors such as informal peer grief-support groups, sense of cohesiveness among HCSWs and task orientation enabled HCSWs to overcome these challenges. To conclude, induction and training programmes, a defined period of preceptorship, appropriate support, supervision and clearly defined role boundaries may be helpful in reducing the challenges identified in HCSWs' roles.

Early support visits by district nurses to cancer patients at home: a multi-perspective qualitative study

BACKGROUND

Many palliative cancer patients spend much of their last year at home. In the UK, district nurses make frequent support visits to patients and carers at this time, yet surprisingly little is known about their supportive role in palliative care. Current studies are limited to district nurses' reports of practice, which offer limited insight into their content. Patients' and carers' views on district nurse support visits are largely unknown.

AIM

To present findings of a multi-perspective study that explored how district nurse early support visits are both described and carried out.

DESIGN

Focus groups with district nurses to explore views on the purpose of early support visits. Observation of support visits to identify how they are conducted. Patient and carer interviews to elucidate and verify district nurse data.

SETTING AND PARTICIPANTS

Participants included 58 district nurses, 10 palliative care patients and nine carers from four Primary Care Trusts in contrasting urban and rural locations.

RESULTS

District nurses had difficulty articulating early support visits. Observations however revealed a complex role comprising extensive physical and practical assessments, practical interventions, information giving, liaison, facilitation and referral. Patients and carers confirmed that they felt valued, reassured and supported by district nurses.

CONCLUSIONS

A multi-perspective approach provided new insights into district nurse support visits. Monitoring work described appears to have additional psycho-social benefits for patients and carers. The supportive role of district nurses needs to be clearly articulated and recognised so that colleagues, patients and carers access this valuable resource for palliative care patients.

Providing in-home palliative care within a generalist caseload: a chance for nurses to reflect on life and death

At a time when the need for in-home palliative care is on the rise, the aim of this interpretive phenomenological study was to understand the experiences of homecare nurses providing palliative care within a generalist caseload. Eight such nurses from one district of Quebec were interviewed. Data analysis was carried out according to the phenomenological method developed by Giorgi. Three themes emerged from the analysis: supporting the patient and his/her family, being concerned about providing quality care, and being confronted with death fosters personal development. The findings that gave rise to the first two themes echo similar findings from the literature, but those from which the third theme emerged are more novel. Important considerations for personal and professional development are extrapolated from these findings.

District nurse role in end-stage COPD: a review

District Nurses (DNs) are core providers of end-stage care in the community but appear to have little contact with patients suffering from non-malignant diseases, such as chronic obstructive pulmonary disease (COPD). This review found limited literature describing the role of DNs in end-stage COPD care, and the studies that did touch on the subject restricted their discourse to the frequency of interaction. A clear bias of end-of-life services to patients with malignancy was noted, as well as a call for community services to extend care to all end-stage patients regardless of underlying disease. In addition, there was a further call for DNs to apply a more holistic approach to care, as described in the literature. Finally, it was clear that while ongoing community intervention is necessary for end-stage COPD patients, support and training is essential to equip DNs to care for these vulnerable patients.

'You're whatever the patient needs at the time': the impact on health and social care professionals of supporting people with epidermolysis bullosa

OBJECTIVES

Professionals working with people who encounter pain and suffering can experience adverse emotional effects themselves. However, to provide effective support it is necessary to understand specific work-related experiences and contexts. This study investigated the impact on professionals of supporting people with the skin condition 'epidermolysis bullosa'.

METHODS

A two-part mixed methods design was utilized. Part one comprised interviews with specialist nursing and social care professionals (n = 7). Part two comprised a survey administered to a range of EB specialist professionals (n = 26).

RESULTS

The interview data were analysed inductively and informed the survey design. The survey data were analysed deductively and compared to the interview findings. Three integrated themes were subsequently depicted: the intensity and depth of involvement; managing with limited resources; and the need to look after yourself.

DISCUSSION

Findings show the ways in which the work can affect well-being and how the impact is intensified by the low numbers of specialist professionals in the field. But the support of team members, access to effective supervision and the rewards of working with a remarkable population make the professional role worthwhile. Adequate clinical supervision, skills training and access to multi-disciplinary expertise were all highlighted as beneficial for well-being.

A literature review of the role of the specialist palliative care community nurse

This article reviewed international research to obtain an improved understanding of the role defined in the literature as the specialist palliative care community nurse (SPCCN). Developments in cancer treatment and palliative care have lead to improved symptom control and increased prognosis for palliative care patients. In response, there has been a change to the role of the SPCCN indicating a move from a generalized, to specialist, community nurse who provides a consultancy service, thus causing role ambiguity. Within the literature, three themes emerged in defining the role of the community palliative care nurse: communication and collaboration; a clarification of the role; and the role of referral. This review found that there was a blurring of professional boundaries amongst the palliative care team and that the SPCCN has a capacity to coordinate and provide expertise in delivering complex symptom control to patients and their families.

An investigation of emotional wellbeing and its relationship to contemporary nursing practice

This paper is an investigation of emotional wellbeing and its relationship to contemporary nursing practice for women community health nurses (CHNs) who are providing palliative care. Palliative care provision has been acknowledged as a source of job satisfaction for many nurses however emotional interactions place increasing strain on nurses' wellbeing. Psychosocial aspects of care are reported as having a personal as well as a professional impact. Work related stress places nurses at increased risk of harm and impaired wellbeing. An emancipatory methodology was chosen for this study. Semi-structured interviews and reflective journaling were the methods used. The data was collected over a 16-month period during 2006-2007. There were fifteen participants. This qualitative study explored Australian rural and urban community nurses' experiences with wellbeing, emotional work and their professional practice. The findings revealed opposing social forces, an inner 'dialectical' tension between the nurses' expectations of their professional practices and what is valued in their practice settings. In terms of emotional wellbeing, two overarching themes will be discussed: feeling balanced and feeling out of balance. Workplace environments that were not always conducive to healing increased the emotional strain on nurses. Nurses' work promotes the healing of others therefore to deny the healing of nurses' is to deny others of healing. The need for further qualitative research investigating the emotional wellbeing and professional practice of community nurses who provide palliative care is necessary.

Nursing the dying within a generalist caseload: a focus group study of district nurses

BACKGROUND

Community nurses (members of UK District Nursing teams) have a key role in the provision of palliative care in the community in the UK. However, their views about delivering palliative care within their generalist workload have not been assessed.

OBJECTIVES

To explore community nurses' perceptions of their palliative care role, and their provision of such care within the context of their wider generalist workload.

DESIGN

Focus group study.

SETTING

Four Primary Care Trusts in London, UK.

PARTICIPANTS

A purposive sample of 51 community nurses.

METHODS

Nine focus groups (four to seven participants in each) were conducted between 2003 and 2004. Data were analysed using the framework approach.

RESULTS

We identified five broad themes. Community nurses felt they had a central role in the provision of palliative care to patients at home. Many felt this role was not recognised by other health care professionals and managers. Palliative care was identified as unpredictable and time-consuming within a pressurized context characterised by staff shortages and consequent lack of time. Whilst rewarding, palliative care took its toll on nurses' emotions, compounded by a perceived lack of formal support. Finally, undertaking palliative within a generalist workload created additional pressures for community nurses.

CONCLUSIONS

The integration of palliative care into routine generalist caseloads generated workload stresses in time and emotion. Community nurses felt their palliative care role and its impact on workload was not adequately acknowledged. Palliative care specific support mechanisms and ways of working may be necessary to meet patients' and professionals' expectations of effective, compassionate care at the end of life.