Family caregivers' experience of communication with nursing home staff from admission to end of life during the COVID-19 pandemic: A qualitative study employing a transitional perspective

OBJECTIVES

Family caregivers' (FCs) caregiving in nursing home (NH) moves across 3 main phases: transitioning relatives to long-term care, worsening of a relative's conditions, and end of life; each phase brings specific challenges that FCs must confront. Moreover, during the COVID-19 pandemic, strict mandatory visitor restrictions affected communication modalities. This study explored FCs' experience of communication with NH staff during the COVID-19 pandemic from admission to end of life.

METHODS

A descriptive qualitative study with inductive content analysis was performed in 7 Italian NHs from May to June 2021. NH managers purposively identified 25 FCs at different phases of their caregiving trajectory: transitional (i.e., admission in the previous 8 weeks, n = 8), deterioration-in-condition (i.e., acknowledged changes in care needs of their relative after trigger events, n = 10), and end-of-life phase (i.e., death expected in the next weeks or a few months, n = 7), who were interviewed.

RESULTS

Regardless the phase of caregiving trajectory, what mattered most to FCs was the opportunity to have regular and sensitive discussions with health-care professionals. The need of in-person communication increased nearing death. The COVID-19 pandemic enhanced FCs' need to interact with health-care professionals they trusted. Knowledge of residents' preferences mitigated FCs' turbulent emotions throughout the overall caregiving trajectory.

SIGNIFICANCE OF RESULTS

Findings suggest that in-person contacts should be prioritized and facilitated when possible, particularly at the end of life; nonetheless, meaningful communication can occur also through remote modalities. Investments in training health-care professionals about effective long-distance communication and supportive skills can help trusting relationships to be established. Open discussions about residents' care preferences should be encouraged.

[Health and social care in an urban nursing home providing healthcare services and primary care's role: A qualitative study with residents, relatives and professionals]

AIM

To identify the elements involved in adequate health and social care for old people living in nursing homes, determine their possible barriers and enablers and define primary care's role in it.

DESIGN

Qualitative study with phenomenological approach.

SETTING

State funded private nursing home and its corresponding primary care center in the southeastern urban area of Madrid.

PARTICIPANTS

Elderly residents, their relatives, and professionals from the nursing home and the primary care center.

METHOD

Five focus groups were conducted between November 2019 and January 2020, with semi-structured interviews based on the variables of analysis and themes related to the objectives. The sessions were recorded and transcribed. An open and axial coding was performed to identify categories after a triangulation of the data.

RESULTS

The elements of adequate care identified are individualized care, promotion of autonomy, adequate information to residents and relatives, quality of services, coordination between professionals, and a continuous end of life care. The main barriers are the deficit of professionals, the differences in expectations between users and workers, and the organizational gap between the healthcare system and nursing homes providing healthcare services. The role identified for primary care is mostly bureaucratic.

CONCLUSIONS

It is necessary to continue exploring these elements and to outline the role of primary care in nursing homes with different characteristics.

Patient, carer and health professional experiences of end-of-life care services in chronic obstructive pulmonary disease: an interpretive synthesis of qualitative studies

The objective of this systematic literature review is to identify patients’, carers’ and health professionals’ reported perspectives of end-of-life care services for severe chronic obstructive pulmonary diseases (COPD) and explore whether services are person-centred and integrated according to WHO definitions. The systematic review was qualitative with interpretive synthesis. The data sources included MEDLINE, CINAHL, Emcare, Embase, Cochrane (CENTRAL), Joanna Briggs Institute and PsycINFO databases from inception to 23 May 2022 limited to the English language. Qualitative studies were eligible if they reported open-ended patients,’ carers’ or healthcare professionals’ experiences of end-of-life care for severe COPD. Qualitative data were categorised according to healthcare stakeholder groups and conceptualised within a health services network using the Actor-Network Theory. Eighty-seven studies proved eligible. Eleven stakeholder groups constituted the healthcare services network for severe COPD (in order of frequency of interactions with other stakeholders): secondary care, primary care, community services, acute care, palliative care, carer, healthcare environment, patient, government, social supports and research. When evaluating the network for evidence of patient-centred care, patients and carers received input from all stakeholder groups. The relationship between stakeholder groups and patients was largely unidirectional (stakeholders towards patients) with low influence of patients towards all stakeholder groups. There was limited interaction between specific healthcare services, suggesting low network integration. Government services, research and social supports had few connections with other services in the healthcare network. Multiple intersecting health, community and government services acted on patients, rather than providing patient-informed care. Health services provided poorly integrated services for end-of-life care for severe COPD.

PROSPERO registration number

CRD42020168733.

The role of end-of-life communication in contributing to palliative-oriented care at the end-of-life in nursing home

BACKGROUND

Clear communication about a person's poor prognosis and limited treatment choices improves the quality of end-of-life care.

AIMS

To investigate how end-of-life communication may contribute to palliative-oriented care at the end-of-life in nursing homes according to both families' and nurses' perspective. Secondly, to identify the contextual factors internal to the nursing home that may influence the timing and quality of communication. Thirdly, to confirm the foundations for a first theory of end-of-life communication.

METHOD

This study is a descriptive two-tailed embedded multiple-case study. A secondary analysis of 23 family carer-nurse paired interviews was performed.

FINDINGS

Several contextual factors influenced the timing and quality of communication that, in turn, impacted end-of-life care by promoting family understanding, fostering shared decision-making between healthcare professionals and resident/family carers, and improving the knowledge of residents' and family carers' preferences (ie drivers of transition towards palliative-oriented care). Family carers' preferences had the strongest influence in guiding the care approach, while residents' preferences were poorly known and had a limited impact on the end-of-life care goal. Complex and dynamic interactions within and between drivers and contextual factors emerged, providing preliminary evidence for a first end-of-life communication theory.

CONCLUSION

Findings suggest the need to promote a familiar atmosphere and quality relationships, and improve the knowledge of a resident's preferences to ensure that end-of-life care is consistent with their desires.

Living, loving and letting go-navigating the relational within palliative care of older people in long-term care facilities: An action research study

BACKGROUND

Long term care facilities are important environments for the delivery of palliative care, which includes end of life care. Despite this, staff may feel this care focus is separate to their roles. Consequently, this study explores and makes visible how palliative care is understood in long term residential care facilities for older people. It focuses on how relationships with residents and families are experienced by nurses and health care assistants and how this influences the introduction and provision of palliative care to older people in long term care facilities.

OBJECTIVES

To develop an understanding of what palliative care means to staff caring for older people in residential care.

METHODS

A co-operative inquiry action research approach was used. A total of 18 healthcare assistants and 16 registered nurses in two older person long term care facilities participated in co-operative inquiry groups. Co-inquirers reflected on deaths that occurred over a 6-month period and generated narratives on their relationships in the context of palliative care.

RESULTS

Three themes were identified to describe relationships which were immersed in an ethos of person-centred care. These were living, loving and letting go. Living rather than dying was the predominant focus of care. Loving described deep engagement with older people and families while letting go navigated the dying process.

CONCLUSIONS

Staff in nursing homes experience deep attachments to residents when delivering palliative care and end of life care. There is a need to understand these relationships and how they impact on the understanding and integration of palliative care in older person residential care as well as acknowledging and addressing staff's grief processes to enhance resilience.

'Bare-bones' to 'silver linings': lessons on integrating a palliative approach to care in long-term care in Western Canada

Background

‘Whole-person’ palliative approaches to care (PAC) are important for enhancing the quality of life of residents with life-limiting conditions in long-term care (LTC). This research is part of a larger, four province study, the ‘SALTY (Seniors Adding Life to Years)’ project to address quality of care in later life.

A Quality Improvement (QI) project to integrate a PAC (PAC-QI) in LTC was implemented in Western Canada in four diverse facilities that varied in terms of ownership, leadership models, bed size and geography. Two palliative ‘link nurses’ were hired for 1 day a week at each site over a two-year time frame to facilitate a PAC and support education and training.

This paper evaluates the challenges with embedding the PAC-QI into LTC, from the perspectives of the direct care, or front-line team members. Sixteen focus groups were undertaken with 80 front-line workers who were predominantly RNs/LPNs (n = 25), or Health Care Aides (HCAs; n = 32). A total of 23 other individuals from the ranks of dieticians, social workers, recreation and rehabilitation therapists and activity coordinators also participated. Each focus group was taped and transcribed and thematically analyzed by research team members to develop and consolidate the findings related to challenges with embedding the PAC.

Results

Thematic analyses revealed that front-line workers are deeply committed to providing high quality PAC, but face challenges related to longstanding conditions in LTC notably, staff shortages, and perceived lack of time for providing compassionate care. The environment is also characterized by diverse views on what a PAC is, and when it should be applied. Our research suggests that integrated, holistic and sustainable PAC depends upon access to adequate resources for education, training for front-line care workers, and supportive leadership.

Conclusions

The urgent need for integrated PAC models in LTC has been accentuated by the current COVID-19 pandemic. Consequently, it is more imperative than ever before to move forwards with such models in order to promote quality of care and quality of life for residents and families, and to support job satisfaction for essential care workers.

Qualitative research on end-of-life communication with family carers in nursing homes: A discussion of methodological issues and challenges

Aim

To identify and summarize the challenges of conducting qualitative research exploring end-of-life communication between healthcare providers and bereaved family carers in nursing homes.

Design

A descriptive qualitative study based on in-the-field-notes and research diaries collected during a primary study involving 32 bereaved family carers and 14 nurses across 13 Italian nursing homes in 2018-2019.

Methods

Two trained female nurses conducted semi-structured, in-depth, open-ended interviews and recorded "in action" (i.e. reflections reported as in-the-field-notes) and "on action" (i.e. retrospective reflections within the team reported immediately in the research diaries) narratives, with the aim of identifying challenges encountered during the research process. A content analysis process was performed to analyse the narratives collected.

Results

We identified three major categories of challenges: (a) obtaining approval from the ethical committee; (b) approaching nursing homes and family carers; and (c) dealing with participant-related impairments (i.e. memory, emotional, physical).

What contributes to family carers' decision to transition towards palliative-oriented care for their relatives in nursing homes? Qualitative findings from bereaved family carers' experiences

OBJECTIVES

Family carers (FCs) of nursing home (NH) residents are best placed to notice deteriorations that signal impending death in their relative, which can open a conversation with healthcare professionals (HCPs) about adjusting the care plan. We explored contributors to bereaved FCs' decision to transition towards palliative-oriented care for their relatives in NHs.

METHODS

This qualitative descriptive study used a phenomenological design. Thirty-two bereaved FCs across 13 Italian NHs completed semi-structured interviews. Additional data were collected on NH referrals to palliative care services (PCS) in the 6 months before study start and treatments provided in the last week of life. Content analysis with a combined inductive and deductive approach was applied to identify codes and fit them into an a priori framework. When codes did not fit, they were grouped into new categories, which were finally gathered into themes.

RESULTS

FCs reported four types of "trigger events" that made them doubt that their relative would recover: (1) physical deterioration (e.g., stopping eating/walking or swallowing problems); (2) social confirmation (e.g., confirming their relative's condition with friends); (3) multiple hospitalizations; and (4) external indicators (e.g., medical examinations by external consultants). A "resident-centered environment" helped FCs recognize trigger events and "raise awareness of the possibility of death"; however, the "need for reassurance" was pivotal to a "gradual transition towards palliative-oriented care". When participants did not recognize the trigger event, their relative continued to receive curative-oriented care. NHs that referred residents to PCS discussed palliative-oriented care more frequently with FCs, had a lower nurse-to-resident and nurse aide-to-resident ratio, and administered more palliative-oriented care.

SIGNIFICANCE OF RESULTS

Trigger events represent an opportunity to discuss residents' prognosis and are the starting point for a gradual transition towards palliative-oriented care. Adequate staffing, teamwork, and communication between FCs and healthcare professionals contribute to a sensitive, timely shift in care goals.

Accuracy in Surrogate End-of-Life Medical Decision-Making: A Critical Review

BACKGROUND

Increasing age is accompanied by a greater need for medical decisions, due in part to age-related increases in chronic disease and disability. In later life, medical decisions about end-of-life care in particular are likely. However, a significant percentage of these decisions are made by surrogate decision-makers. "Surrogates" are most often instructed to use the substituted judgment standard and make decisions that patients would choose if they were able. Whether surrogates make decisions that adequately match patients' preferences is a concern. Surrogates are generally poor predictors of patient preferences (Shalowitz et al., 2006). However, no critical review of this literature has yet been published.

METHOD

A critical review was conducted to summarise and provide a methodological critique of 25 studies.

RESULTS

These studies generally concur that patient-surrogate agreement on medical decisions is poor. However, this conclusion is qualified by inconsistencies in methodological quality and the potentially limited generalisability of these findings.

CONCLUSIONS

Clinical research incorporating standardised hypothetical decision-making protocols, as well as triangulated data collection methods, would bolster confidence in future findings. Investigations prioritising the surrogate decision-making process, rather than solely the decisional outcome, could better identify ways to improve the decision-making process for incapacitated patients.

Palliative care delivery in residential aged care: bereaved family member experiences of the Supportive Hospice Aged Residential Exchange (SHARE) intervention

Background

The supportive hospice aged residential exchange (SHARE) is a new model of palliative care education that has been designed for residential aged care. The goal of SHARE is to help clinical staff improve palliative care within residential aged care facilities and to improve specialist palliative care nurses’ knowledge and skill to care for frail older people.

Method

The experiences of 18 bereaved families concerning the palliative care journey (both at the start and finish of a one-year implementation of SHARE) were explored using semi-structured interviews.

Results

Three themes were important to bereaved families’ experience: communication with staff, systems of care, and hospice involvement. Sub-themes indicating changes in these three components of care between the start and finish of SHARE was identified. A fourth theme highlighted challenges (relationship with GP, staff shortages, and turnover) that continued across SHARE.

Conclusion

Findings indicated that SHARE benefited families (improved communication and support) through the end of life journey of their relatives, but challenges remained.

A qualitative study of nurses' perspective about the impact of end-of-life communication on the goal of end-of-life care in nursing home

BACKGROUND

With a growing nursing home population suffering from chronic progressive illnesses and evolving patterns of comorbidities, end-of-life communication takes on a critical role to enable healthcare professionals to gather information about the resident's wishes for care at the end-of-life and organise the care plan accordingly.

AIM

To explore nurses' perspective about the process by which end-of-life communication impacts on the goal of end-of-life care in nursing home residents.

DESIGN

A qualitative descriptive research design based on thematic analysis was performed. Fourteen nurses involved in the care of residents during their last week of life were recruited across 13 Italian nursing homes and accounted for 34 semi-structured interviews. A combined approach of analysis that incorporated a data-driven inductive approach and a theory-driven one was adopted.

RESULTS

Twelve themes described how end-of-life communication may contribute to adjust the care plan in nursing home according to the nurses' perspective. Five antecedents (i.e. life crisis or transitions, patient-centered environment, arising the question of possible dying, quality of relationships and culture of care) influenced the establishment and quality of communication, and five attributes depicted the characteristics and potential mechanisms of end-of-life communication (i.e. healthcare professional-resident and healthcare professional-family carers communication, knowledge of family carers' preferences, knowledge of residents' preferences, family carers and residents understanding, and shared decision-making), while curative-oriented and palliative-oriented care goals emerged as consequences.

CONCLUSION

This study provides insight into the nursing perspective of end-of-life communication between healthcare professionals and bereaved family carers of nursing home residents. Several factors influenced the occurrence and quality of end-of-life communication, which contributed to the transition towards palliative-oriented care by using and improving knowledge about family cares' and resident's preferences for end-of-life care, promoting family carers and residents understanding about prognosis and treatments available, and fostering shared decision-making.

Mechanisms by which end-of-life communication influences palliative-oriented care in nursing homes: A scoping review

OBJECTIVE

End-of-life communication has been largely recognized to promote quality end-of-life care in nursing home (NHs) by increasing residents' likelihood of receiving comfort-oriented care. This scoping review summarizes what is known about the potential mechanisms by which end-of-life communication may contribute to palliative-oriented care in NHs.

METHODS

Using the framework proposed by Arksey and O'Malley and refined by the Joanna Briggs Institute methodology, five literature databases were searched. We extracted 2159 articles, 11 of which met the inclusion criteria: seven quantitative, three qualitative, and one mixed-methods study.

RESULTS

Three mechanisms were identified: a) promotion of family carers' understanding about their family member's health condition, prognosis, and treatments available; b) fostering of shared decision-making between health care professionals (HCPs) and residents/family carers; and c) using and improving knowledge about residents' preferences.

CONCLUSION

Family carers' understanding, shared decision-making, and knowledge of residents' preferences contribute to palliative-oriented care in NHs.

PRACTICE IMPLICATIONS

Discussions about end-of-life should take place early in a resident's disease trajectory to allow time for family carers to understand the condition and participate in subsequent, mindful, shared decision-making. HCPs should conduct systematic and thorough discussions about end-of-life treatment options with all cognitively competent residents to promote informed advance directives.

An instrument to assess the education needs of nursing assistants within a palliative approach in residential aged care facilities

BACKGROUND

Providing quality palliative care in residential aged care facilities (RACFs) (aged care homes) is a high priority for ageing populations worldwide. Older people admitted to these facilities have palliative care needs. Nursing assistants (however termed) are the least qualified staff and provide most of the direct care. They have an important role at the frontline of care spending more time with residents than any other care provider but have been found to lack the necessary knowledge and skills to provide palliative care. The level of competence of this workforce to provide palliative care requires evaluation using a valid and reliable instrument designed for nursing assistants' level of education and the responsibilities and practices of their role.

METHOD

The overall study purpose was to develop and test an instrument capable of evaluating the knowledge, skills and attitudes of nursing assistants within a palliative approach in RACFs. Development consisted of a four-phase mixed-methods sequential design. In this paper, the results and key findings following psychometric testing of the instrument in Phase 4 is reported using data collected from a random sample of 17 RACFs and 348 nursing assistants in the Greater Sydney region. Study hypotheses were tested to confirm discriminative validity and establish the utility of the instrument in both research and training assessment.

RESULTS

Individual item properties were analysed for difficulty, discrimination and item-total correlations. Discriminative and structural validity, and internal consistency and test-retest reliability were demonstrated. Three separate questionnaires comprising 40 items were finalised: The Palliative Approach for Nursing Assistants (PANA)_Knowledge Questionnaire (17 items), the PANA_Skills Questionnaire (13 items) and the PANA_Attitudes Questionnaire (10 items).

CONCLUSIONS

This study provides preliminary evidence for the validity and reliability of three new questionnaires that demonstrate sensitivity for nursing assistants' level of education and required knowledge, skills and attitudes for providing a palliative approach. Implications for practice include the development of palliative care competencies through structured education and training across this workforce, and ongoing professional development opportunities for nursing assistants, especially for those with the longest tenure.

Good end-of-life care in nursing home according to the family carers' perspective: A systematic review of qualitative findings

BACKGROUND

Nursing homes are becoming a common site where delivering end-of-life care for older adults. They often represent the junction between the curative and the palliative phase.

AIM

To identify the elements that nursing home residents' family carers perceive as good end-of-life care and develop a conceptual model of good end-of-life care according to the family perspective.

DESIGN

Systematic review (PROSPERO no. 95581) with meta-aggregation method.

DATA SOURCES

Five electronic databases were searched from inception between April and May 2018. Published qualitative studies (and mixed-method designs) of end-of-life care experience of nursing home family carers whose relative was dead or at the end-of-life were included. No language or temporal limits were applied.

RESULTS

In all, 18 studies met inclusion criteria. A 'life crisis' often resulted in a changed need of care, and the transition towards palliative care was sustained by a 'patient-centered environment'. Family carers described good end-of-life care as providing resident basic care and spiritual support; recognizing and treating symptoms; assuring continuity in care; respecting resident's end-of-life wishes; offering environmental, emotional and psychosocial support; keeping family informed; promoting family understanding; and establishing a partnership with family carers by involving and guiding them in a shared decision-making. These elements improved the quality of end-of-life of both residents and their family, thus suggesting a common ground between good end-of-life care and palliative care.

CONCLUSION

The findings provide a family-driven framework to guide a sensitive and compassionate transition towards palliative care in nursing home.

Striking a Balance: A Qualitative Study of Next of Kin Participation in the Care of Older Persons in Nursing Homes in Sweden

Most of the care in nursing homes is palliative in nature, as it is the oldest and the frailest people who live in nursing homes. The aim of this study was to explore next of kin's experiences of participating in the care of older persons at nursing homes. A qualitative design was used, based on semi-structured interviews with 40 next of kin, and analyzed using qualitative content analysis. An overarching theme emerged, a balancing act consisting of three categories: (1) visiting the nursing home; (2) building and maintaining relationships; and (3) gathering and conveying information. The next of kin have to balance their own responsibility for the older person's wellbeing by taking part in their care and their need to leave the responsibility to the staff due to critical health conditions. The next of kin wanted to participate in care meetings and conversations, not only in practical issues. The findings indicate the need to improve the next of kin's participation in the care as an equal partner. Increased knowledge about palliative care and decision-making of limiting life-prolonging treatment may lead to a higher quality of care.

O cuidado cotidiano na perspectiva de idosos independentes e de seus familiares mais próximos

Objetivo: identificar cómo el anciano independiente y el familiar más próximo vivencian la relación de cuidado.Metodología: estudio descriptivo y exploratorio, de enfoque cualitativo, realizado en Jandaia do Sul (departamento de Paraná, Brasil), con 15 ancianos independientes y sus respectivos familiares. Los datos fueron recolectados en junio de 2012 por medio de entrevista semi-estructurada y sometidos al análisis de contenido, en la modalidad temática.Resultados: el promedio de edad de los ancianos fue de 70 ± 9 años; el 85 % de los participantes (13) era del sexo femenino. El promedio de edad de los familiares fue de 45 ± 5 años, siendo el 85 % (13) del sexo femenino (9 hijas y 4 nueras); los dos familiares del sexo masculino eran hijos de los ancianos. El análisis de las informaciones posibilitó la identificación de dos categorías: La percepción del anciano independiente sobre el cuidado recibido y La percepción del familiar sobre el cuidado ofrecido.Conclusión: el cuidado ofrecido por el familiar era percibido por los ancianos independientes de modo impositivo y controlador, en desacuerdo con la intención del familiar, que era ofrecer cuidados y atención. Esta disonancia en la percepción de ambos termina por sobrecargar la relación entre ellos.