Spiritual Caring: End of Life in a Nursing Home

Exploring the Process of Spiritual Health of the Elderly Living in Nursing Homes: A Grounded Theory Study

BACKGROUND

Spiritual health is one of the important dimensions of the elderly's health, which plays an important role in other dimensions of their health. This study aimed to explain the process of spiritual health of the elderly living in nursing homes.

METHODS

This grounded theory study was conducted in 4 nursing homes in the city of Arak Iran between October 2019 and September 2020. The participants were 24 elderly people living in nursing homes, two health care providers, one nurse and one family member, first selected through purposive sampling and then, through theoretical sampling. The data were collected through semi-structured interviews and field notes. All the interviews were transcribed verbatim and analyzed based on Strauss and Corbin approach (2008).

RESULTS

Six main categories were identified, including helplessness, inefficient supportive environment, spiritual distress, seeking support, relative improvement of spiritual health and factors affecting spiritual health, each of which explains a part of the whole process of spiritual health of the elderly living in nursing homes.

CONCLUSION

Supporting the elderly living in nursing homes is necessary in order to meet their spiritual needs and preserve and promote their spiritual health.

Self-transcendence among adults 65 years and older: A meta-analysis

INTRODUCTION

Self-transcendence is a human capacity for wellbeing by expanding one's personal boundaries and may act as a health-promoting resource among adults ≥65 years. Therefore, the objectives of this meta-analysis were to determine the mean score of self-transcendence based on place of residence and gender, and to evaluate the correlations of self-transcendence with meaning, sense of coherence, resilience and depression.

METHODS

Based on inclusion criteria, 13 studies were included. Orwin Safe N and Egger's test assessed publication bias. The mean score of self-transcendence and the correlation coefficients of the selected variables were estimated by random effects models.

RESULTS

The self-transcendence mean score (n = 1634) was low (M = 43.6) and a bit lower among those staying in care facilities (M = 42.8), but did not vary significantly across gender. The correlation coefficients were self-transcendence_depression (r = -0.40), self-transcendence_meaning-in-life (r = 0.53), self-transcendence_resilience (r = 0.50) and self-transcendence_sense of coherence (r = 0.28). The correlation coefficients, except for meaning-in-life, were homogeneous.

CONCLUSION

In a health-promoting perspective, the concept of self-transcendence can help to better understand wellbeing among older individuals and provide guidance for health professionals in facilitating wellbeing and health. The concept and theory of self-transcendence can inspire health professionals in realising new health-promoting approaches to support older individuals in maintaining health, wellbeing and independency.

"Sometimes I've gone home feeling that my voice hasn't been heard": a focus group study exploring the views and experiences of health care assistants when caring for dying residents

Background

In most developed countries, Health Care Assistants comprise a significant, and growing, proportion of the residential aged care workforce. Despite the fact that they provide the majority of direct care for residents, little is known about a key care aspect of their work, namely their experience of caring for dying residents.

Methods

Twenty-six Health Care Assistants working in aged residential care facilities in Auckland, New Zealand participated in six focus group discussions. Focus groups were designed to explore the experiences of Health Care Assistants caring for imminently dying residents in aged care facilities and to identify barriers and facilitators to their work in this area. The focus groups were digitally recorded, transcribed verbatim and analysed using a general inductive approach.

Results

Participants confirmed that Health Care Assistants provide the majority of hands on care to dying residents and believed they had a valuable role to play at this time due to their unique ‘familial’ relationship with residents and families. However, it was apparent that a number of barriers existed to them maximising their contribution to supporting dying residents, most notably the lack of value placed on their knowledge and experience by other members of the multidisciplinary team. Whilst a need for additional palliative and end of life care education was identified, a preference was identified for hands on education delivered by peers, rather than the didactic education they currently receive.

Conclusion

Given ageing populations internationally coupled with a constrained health budget, the role of Health Care Assistants in most developed countries is likely to become even more significant in the short to medium term. This study makes a unique contribution to the international literature by identifying the barriers to caring for dying residents experienced by this valuable sector of the aged care workforce. These data have the potential to inform new, innovative, interventions to address the urgent need identified to improve palliative and end of life care management in aged care internationally.

Stigma, the medical model and dementia care: Psychological growth in senior health professionals through moral and professional integrity

Minimal research explores the impact of a career in dementia care on senior health professionals. This study sought positive and negative subjective interpretations from seven senior health professionals regarding their experiences in dementia care. Data from semi-structured interviews were analysed using interpretative phenomenological analysis (IPA). One superordinate theme, Honouring stigmatised self, overarched four sub-themes: Systemic stigma, Invalidated, Self-respect and Moral integrity and Growth. Stigma was interpreted as systemically entrenched minimisation of aged care and the aged-care workforce, including poor remuneration and training. Participants experienced peer invalidation particularly when attempting to resolve complex professional and moral challenges in dementia care. These often occurred in the context of efforts to individualise care, constrained within a medical model. Paradoxically, external invalidation motivated a search for redefining ‘self’ and moral integrity. By wisely acknowledging career experience, growthful domains of self-respect, optimism, humility and innovation defined professional practice and personal choices. Implications are discussed.

Nurses' and care workers' experiences of spiritual needs in residents with dementia in nursing homes: a qualitative study

Background

The aim of the study was to investigate nurses’ and care workers’ experiences of spiritual needs among residents with dementia in nursing homes. Nurses claim to practice holistic nursing. Nevertheless, there is little knowledge about how to recognise spiritual needs in residents with dementia.

Methods

The study was conducted using a qualitative method with an exploratory design. Eight focus- group interviews in four Norwegian nursing homes were performed from June 2011 – Jan 2012. Using open-ended research questions, a total of 31 participants were asked to share their understanding and experiences regarding residents’ spiritual needs. The interviews were analysed using a phenomenological – hermeneutical method.

Results

The nurses’ and care workers’ experiences of residents’ spiritual needs were related to three main themes; i) The need for serenity and inner peace, described as “contemplative and restful moments” and “calmness due to familiarity”, ii) The need for confirmation, described as “love and proximity” and iii) The need to express faith and beliefs, described as “participate in worship and prayers” and “approaching death”.

The comprehensive analyses revealed that the nurses believe the residents’ spiritual needs were linked to the residents’ previous sources of finding meaning, in relation to inter-personal, intra-personal and trans-personal dimensions in residents’ lives.

Conclusions

Nurses' and care workers’ experiences of spiritual needs in people with dementia are very similar to the findings for the general population regardless of the severity of the dementia. The study’s relevance to clinical practice indicates the importance of developing more knowledge about how people with dementia in nursing homes express spiritual needs and how to observe and interpret such needs.

The FACIT-Sp spiritual well-being scale: an investigation of the dimensionality, reliability and construct validity in a cognitively intact nursing home population

BACKGROUND

Spiritual well-being has been found to be a strong individual predictor of overall nursing home satisfaction and a fundamental dimension of global as well as health-related quality-in-life among nursing home patients. Therefore, access to a valid and reliable measure of spiritual well-being among nursing home patients is highly warranted.

OBJECTIVES

The aim of this study was to investigate the dimensionality, reliability and construct validity of the Functional Assessment of Chronic Illness Therapy Spiritual Wellbeing scale in a cognitively intact nursing home population.

DESIGN AND METHOD

A cross-sectional design was applied, selecting two counties in central Norway from which 20 municipalities representing 44 different nursing homes took part in this study. Long-term care was defined as 24-hour care with duration of 6 months or longer. Participants were 202 cognitively intact long-term nursing home patients fulfilling the inclusion criteria. Approval by all regulatory institutions dealing with research issues in Norway and the Management Unit at the 44 nursing homes was obtained. Explorative and confirmative factor analyses as well as correlation with selected construct were used.

RESULTS

Though three items loaded very low (λ = 0.22, 0.26, 0.32) indicating low reliability, the three-factor model for the FACIT-Sp spiritual well-being scale provided an acceptable fit (χ(2) = 101.15 (df = 50), p-value <0.001, RMSEA = 0.075 p = 0.030, NFI = 0.90, GFI = 0.91, AGFI = 0.85) for older nursing home patients, demonstrating acceptable measurement reliability. Construct validity was supported by significant correlations in the hypothesised direction with the selected constructs.

CONCLUSION

The three-factor model is an improvement over the original two-factor construct, based on these nursing home data. The measure yielded significantly factor loadings, good composite reliability and construct validity.

A community-of-care: the integration of a palliative approach within residential aged care facilities in Australia

In developed countries, residential aged care facilities (RACFs) are increasingly becoming the place of care and site of death for older people with complex chronic illnesses. Consequently, it is becoming ever more relevant for these facilities to provide appropriate complex, as well as end-of-life care for this growing group of people. Evidence-based guidelines for providing a 'palliative approach' were developed and introduced in Australia in 2004, with the emphasis on improving symptom control earlier in the disease trajectory. The aim of the study reported here was to explore the extent to which a palliative approach was being used in the organisation and provision of care for older people with complex needs living in mixed-level (a combination of low- and high-level care) RACFs. This paper primarily reports on the qualitative findings. Two residential aged care organisations, one in rural New South Wales and the other in Sydney, Australia, participated. Data were collected over a 9-month period from May until December 2008. Residents, family members and aged care staff were interviewed. Thematic analysis of participant interviews shows that while the various elements of a palliative approach are incorporated into the care of high-level care residents, the discourse itself is not used. In this paper, we argue for a new conceptualisation of care for people in mixed-level care facilities: a community-of-care, in which a palliative approach is one of several components of the care provided. The findings illuminate aged care staff experiences of providing care to high-level care residents. They also provide valuable insights into high-level care residents' perceptions of their health, care provided and the way in which they foresee their care being provided in future. These findings will be important for informing clinical practice, research and policy in these settings.

Meaning-in-life in nursing-home patients: a correlate with physical and emotional symptoms

AIMS AND OBJECTIVES

To investigate the prevalence of physical and emotional symptoms and the associations between symptoms and meaning-in-life in a cognitively intact nursing-home population.

BACKGROUND

Meaning has been found to be a strong individual predictor of successful ageing and life satisfaction as well as an important psychological variable that promotes well-being. Meaning serves as a mediating variable in both psychological and physical health.

DESIGN AND METHODS

The study employed a cross-sectional design. Data were collected in 2008 and 2009 using the QLQ-C15-PAL quality-of-life questionnaire, the purpose-in-life test and the Hospital Anxiety and Depression Scale. A total of 250 cognitively intact nursing-home patients who met the inclusion criteria were approached and 202 attended.

RESULTS

The prevalence of symptoms was fairly high, with fatigue (57%), pain (49%), constipation (43%) and dyspnoea (41%) as the most frequent physical symptoms, while 30% were depressed and 12% had anxiety. Significant correlations between meaning-in-life and symptom severity were displayed.

CONCLUSIONS

The level of symptom severity among cognitively intact nursing-home patients is high, requiring highly competent staff nurses. Meaning-in-life might be an important resource in relation to a patient's physical and emotional health and global well-being.

RELEVANCE TO CLINICAL PRACTICE

Facilitating patients' meaning-in-life might help reducing symptom severity and fostering quality of life in cognitively intact nursing-home patients. However, advancing staff nurses' competence in palliative care, symptom management and nurse-patient interaction is important for care quality and quality if life in nursing homes.

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.

Nurse-patient interaction is a resource for hope, meaning in life and self-transcendence in nursing home patients

BACKGROUND

Spiritual dimensions such as hope, meaning in life and self-transcendence have been found to be predictors of successful ageing, life satisfaction and well-being in older individuals. Connectedness and communicating with others have been seen to facilitate hope, meaning in life and self-transcendence among nursing home patients.

AIMS

This study aimed to investigate the associations between hope, meaning in life, self-transcendence and nurse-patient interaction in a nursing home population.

DESIGN AND METHODS

A cross-sectional design was employed, collecting data in 44 different Norwegian nursing homes (NHs) from 250 patients who met the inclusion criteria. Approval by all regulatory institutions dealing with research issues in Norway and the Management Unit at the 44 NHs was obtained. A sample of 202 cognitively intact nursing home patients responded to the Herth Hope Index, the Purpose in Life test, the Self-Transcendence Scale and the Nurse-Patient Interaction Scale. A structural equation model (SEM) of the hypothesized relationships between the constructs was tested.

RESULTS

The SEM model fit well with the present data. Significant direct relationships of nurse-patient interaction on hope, meaning in life and self-transcendence were displayed. Meaning and the interconnectedness dimension of hope appeared to be particularly dynamic resources, revealing significant influences on all the constructs in the SEM model tested.

CONCLUSION

Nurse-patient interaction influences hope, meaning in life and self-transcendence in cognitively intact nursing home patients and might be an important resource in relation to patients' health and global well-being. Thus, care providers are above all fundamental for nursing home patients. Advancing caregivers' interacting and communicating skills might facilitate patients' health and global well-being and inspire professional caregivers as they perform their daily care practices. More research of the effectiveness of such strategies is greatly needed.

LIMITATIONS

The SEM model tested comprised 20 variables, indicating a desirable sample size of n = 200, while the present effective sample was n = 187. Also, cross-sectional data do not allow making conclusion on the causality.

Professional caregivers' work with the dying in nursing homes--a Foucault-inspired analysis of discourses in the last decade in a Danish context

International studies on the death of elderly nursing home residents show the complexity in the understanding of the professionals who care for the dying. The aim of this study is to explore the discourses about professional caregivers caring for those dying in Denmark in the last decade. A discourse analysis inspired by Foucault was constructed. The material consists of different source documents: research articles, newspaper articles, theses, books, websites - 35 sources in total. There are constructed six positions of speech, five discourses and three themes: (1) 'the work of the professional caregivers - a complex low-status work'; (2) 'the education of the professionals - the way to ensure a good death or possessing the right qualifications' and (3) 'the vulnerable professionals'. The study concludes that an economical/political discourse is dominating and sets up the frames within which the professionals care for dying residents, although the medical, the social/critical and the religious discourses attempt to speak against it. All positions articulate that the professional caregivers' job has a low status and that it is not possible to provide an optimal care due to lack of time, resources and education. Psychical or mental demands make the professionals vulnerable. The meaning of optimal care varies according to the positions of speech.

Meaning-in-Life in Nursing Home Patients: A Validation Study of the Purpose-in-Life Test

Background: The experience of meaning has been found to be a strong individual predictor of life satisfaction and an important psychological variable that promotes well-being. Therefore, a valid and reliable measurement of meaning-in-life among nursing home patients is highly warranted. Aims: This study intended to further investigate (a) the factor structure of the Purpose-in-Life test (PIL), (b) the reliability of PIL scores, and (c) the construct validity of the PIL test in a nursing home population. Methods: Participants were 202 cognitively intact nursing home patients representing 44 different Norwegian nursing homes. Concerning the dimensionality of the PIL, the following 3 measurement models were tested using confirmatory factor analysis; the original 1-factor, a 2-factor, and a 3-factor model. Results: With the exclusion of 10 items, a previously published and supported 2-factor construct for the PIL by Morgan and Farsides (2007) provided a good fit for older nursing home patients, demonstrating good measurement reliability and construct validity. Conclusion: The 2-factor model by Morgan and Farsides, comprising 10 items, is an improvement over the original 20-items PIL, based on these nursing home data. The measure yielded highly significantly factor loadings, good values for average variance extracted and composite reliability, as well as significant correlations in the expected direction for relevant selected measures; all supporting the construct validity.

A health services framework of spiritual care

AIMS

To introduce a health services framework of spiritual care that addresses the empirical and applied issues surrounding spirituality and nursing practice.

BACKGROUND

Despite over 20 years of study, the concept of spirituality is still under development, which limits application to nursing practice.

METHODS

Three studies using a health services framework are reviewed: (1) a survey study of dying patients and family that describes the providers, types and outcomes of spiritual care; (2) an exploratory study of the process of spiritual care; and (3) a multi-level study of the structure and outcomes of spiritual care in long-term care facilities.

RESULTS

Spiritual care recipients identify family or friends (41%), clergy (17%) and health care providers (29%) as spiritual care providers. The most frequently reported type of spiritual care was help in coping with illness (87%). Just over half (55%) were satisfied with the care that they received. The processes of spiritual care involved: (1) presence, (2) opening eyes, and; (3) co-creating, which was a mutual and fluid activity between patients, family members and care providers. In long term care facilities, decedents who received spiritual care were perceived as receiving better overall care in the last month of life, when compared with those decedents who did not receive spiritual care.

CONCLUSIONS

A health services framework provides a holistic view of spiritual care, one that is consistent with integrated nursing models.

IMPLICATIONS FOR NURSING MANAGEMENT

By focusing on the structure, process and outcome elements of spiritual care within organisational settings, nursing management can develop feasible approaches to implement, improve and evaluate the delivery of this unique type of care.

“They don't just disappear”: Acknowledging death in the long-term care setting

Objective:

The purpose of this study was to describe the value of a formal room blessing ritual held within a long-term care facility, from the perspectives of staff, residents, and family members.

Method:

A qualitative research study involving interviews with staff, residents, and family members was conducted to examine the perceived value of a room blessing ritual.

Results:

Twenty-four room blessing attendees participated in the study (nine staff, eight residents, and seven family members). Attendees felt that the room blessing provided an opportunity to formally acknowledge the death of the resident and their grief; the majority felt that this was a positive experience and that it provided an element of closure. Staff members and residents expressed their appreciation for the opportunity to connect with family members of the deceased to express their condolences during the ritual. Participants also identified the inclusivity of the ritual (i.e., an open invitation to all staff, residents, and family members) as a positive aspect that served as a reminder that others shared in their grief. Staff members felt that blessing the room for the new resident was an important component of the ritual, helping to bridge the gap between mourning and welcoming a new person. Staff, residents, and family members felt that the room blessing positively reflected the mission and values of the facility. The most highly valued aspect of the ritual for all attendees was the sharing of stories about the deceased to celebrate that person's life.

Significance of results:

Long-term care facilities need to recognize that formal supports to manage the bereavement needs of staff and residents, such as a room blessing ritual, should be incorporated into their model for managing end-of-life care, given the relationship between the emotional health of staff and the quality of care provided for residents.

Religiousness, religious coping, and psychological well-being in nursing home residents

OBJECTIVES

To measure the importance of religion among nursing home residents, describe their use of religious coping strategies, and examine the association between religiousness, religious coping, and psychological well-being.

DESIGN

Cross-sectional study.

SETTING

Two nursing facilities in Boston, Massachusetts.

PARTICIPANTS

One hundred forty cognitively intact to moderately impaired long-stay nursing home residents.

MEASUREMENTS

Subjects rated religion as either "not important," "somewhat important," or "very important." Use of religious coping strategies was measured using the 14-item Brief RCOPE. The outcome measure, psychological well-being, was measured with the Bradburn Affect Balance Scale. Covariates included demographic variables and a measure of social engagement, comorbidity, functional status, and mental status. Linear regression was used to examine the association between religious importance and psychological well-being after adjusting for covariates.

RESULTS

Subjects rated the importance of religion as follows: very important (54%), somewhat important (27%), and not important (19%). The mean score on the Affect Balance Scale was 5.9 +/- 2.1 (SD) (range 2-9). After multivariate adjustment, viewing religion as somewhat or very important (versus not important, P=.0019) and absence of negative religious coping strategies (P=.0083) were associated with better psychological well-being (with higher scores on the Affect Balance Scale) (P=.007).

CONCLUSION

Religion was important to most older residents living in 2 religiously affiliated long-term care facilities. Residents for whom religion was somewhat or very important and who did not use negative religious coping strategies are more likely to have better psychological well-being.

The end-of-life experience in long-term care: five themes identified from focus groups with residents, family members, and staff

PURPOSE

We designed this study to examine the end-of-life (EOL) experience in long-term care (LTC) based on input from key stakeholders.

DESIGN AND METHODS

The study consisted of 10 homogeneous focus groups drawn from a purposive sample of LTC residents (2 groups; total n = 11), family caregivers (2 groups; total n = 19), paraprofessional staff (3 groups; total n = 20), and licensed/registered staff (3 groups; total n = 15) from five nursing homes and eight residential care/assisted living communities in North Carolina. We analyzed data by using grounded theory techniques to elicit manifest and latent themes.

RESULTS

Five overarching themes emerged: (a) components of a good death in LTC, (b) normalcy of dying in LTC, (c) the role of relationships in the provision and receipt of care, (d) hospice contributions to care at the EOL in LTC, and (e) stakeholder recommendations for enhancing EOL care in these settings. Underlying these themes was one central category, closeness, based on physical proximity and frequency of contact.

IMPLICATIONS

Findings suggest that promoting collaborative relationships among the four stakeholder groups, increasing social worker involvement, and removing barriers to hospice may enhance the EOL experience in LTC.

An exploratory study of spiritual care at the end of life

PURPOSE

Although spiritual care is a core element of palliative care, it remains unclear how this care is perceived and delivered at the end of life. We explored how clinicians and other health care workers understand and view spiritual care provided to dying patients and their family members.

METHODS

Our study was based on qualitative research using key informant interviews and editing analysis with 12 clinicians and other health care workers nominated as spiritual caregivers by dying patients and their family members.

RESULTS

Being present was a predominant theme, marked by physical proximity and intentionality, or the deliberate ideation and purposeful action of providing care that went beyond medical treatment. Opening eyes was the process by which caregivers became aware of their patient's life course and the individualized experience of their patient's current illness. Participants also described another course of action, which we termed cocreating, that was a mutual and fluid activity between patients, family members, and caregivers. Cocreating began with an affirmation of the patient's life experience and led to the generation of a wholistic care plan that focused on maintaining the patient's humanity and dignity. Time was both a facilitator and inhibitor of effective spiritual care.

CONCLUSIONS

Clinicians and other health care workers consider spiritual care at the end of life as a series of highly fluid interpersonal processes in the context of mutually recognized human values and experiences, rather than a set of prescribed and proscribed roles.

Spiritual care at the end of life in long-term care

BACKGROUND

There is growing attention given to the spiritual needs of dying patients and long-term care (LTC) facilities are common settings in which patients receive care as they approach death.

OBJECTIVES

To describe the sources of support, the structure and processes of spiritual care in LTC, and examine the relationship between these components and family ratings of overall care.

RESEARCH DESIGN

After-death interviews of family members of decedents.

SUBJECTS

Family members of 284 decedent residents from a stratified sample of 100 residential care/assisted living facilities and nursing homes in Florida, Maryland, New Jersey, and North Carolina.

MEASURES

: Interview items included sources of spiritual support, processes of spiritual care, and the impression of overall care (4 = very good, 3 = good, 2 = fair, 1 = poor) for decedents. Facility-level data included demographics, counseling by clergy, on-site religious services, hospice services, and hospice unit.

RESULTS

Most decedents (87%) received assistance with their spiritual needs and those who received spiritual care were perceived by family members to have had better overall care (3.59 vs. 3.25, P = 0.002). Family ratings of care ratings were higher for those who received spiritual support or care from facility staff when compared with those who did not (3.76 vs. 3.49, P < 0.001) and better care was associated with the facilitation of individual devotional activities (3.87 vs. 3.53, P = 0.001).

CONCLUSIONS

Spiritual support and care are associated with better overall care at the end of life for LTC residents, and interventions to improve this type of care may best target interactions between residents and facility staff.