An ecosystem approach to mentoring research faculty in schools of nursing: The pacific northwest interdependence mentoring model

BACKGROUND

Mentoring can facilitate faculty career development and retention. Given ongoing challenges in academic nursing (e.g., shrinking number of experienced mentors), it is necessary to revisit and improve upon existing mentoring models and practices to support current and future nurse researchers.

PURPOSE

To describe the development of a new faculty-to-faculty research mentoring model.

METHODS

Construction of a model describing mentoring needed by research-focused nurse faculty based on analysis of the literature alongside the authors' personal experiences.

FINDINGS

The Pacific Northwest Interdependence Mentoring Model (PIMM) describes academic nursing as an ecosystem that fosters caring, trust, solidarity, equity, openness, and interdependent relationships among research faculty, administration, institutions, and funding sources.

DISCUSSION

Although mentoring environments differ in unique strengths, weaknesses, mission, culture, and values, the PIMM's approach could be applicable for many schools of nursing and beyond to support the growth of the nursing discipline.

The Burden of having to Wonder: Hospice Caregiving Experiences of LGBTQ+ Cancer Family Caregivers

BACKGROUND AND OBJECTIVES

LGBTQ+ people are more likely to be caregivers for family and friends with life-limiting illnesses than non-LGBTQ+ people. LGBTQ+ caregivers may also experience stigma, bias, and discrimination, in addition to caregiving stress. Yet few studies have elicited LGBTQ+ family caregivers' perspectives on their end-of-life (EOL) experiences of home hospice.

RESEARCH DESIGN AND METHODS

We conducted semi-structured interviews with LGBTQ+ family caregivers of home hospice patients (N = 20). Following an interpretive descriptive approach, interview data were audio recorded, transcribed, and iteratively coded, and themes were developed and synthesized.

RESULTS

The burden of having to wonder expressed caregivers' uncertainty and concern about whether their negative experiences were common to all EOL caregivers or stemmed from cultural stigma and provider bias. Participants described how invisibility vs. risks of disclosure, anticipatory anxiety, perceived microaggressions, and protective vigilance increased stress and complicated caregiver-provider communication. Navigating EOL universalities vs. minority realities depicted underlying tensions between commonly assumed universalities of EOL caregiving and LGBTQ+-specific experiences. Providers' discomfort, awkward communication, lack of access to culturally competent EOL support resources, and broader structural and cultural discrimination eroded their sense of connectedness and safety. Together, these themes characterized the impact of minority stress at EOL.

DISCUSSION AND IMPLICATIONS

Our findings suggest that LGBTQ+ hospice caregivers are at risk for minority stress in addition to more common sources of EOL caregiving pressures and thus have specific support and communication needs. Providers must understand this to deliver effective EOL care for all families.

Hospice Family Caregivers' Uncertainty, Burden, and Unmet Needs in Prospective Audio Diaries

Hospice cancer caregivers' (HCCs') burden and unmet needs are well documented in the literature through retrospective, standardized self-report surveys. Hospice cancer caregiver daily experiences of burden and unmet needs are rarely captured within a real-time context. The purpose of this secondary data analysis was to characterize HCCs' day-to-day burden and unmet needs with prospective HCC (N = 50) audio diary data between hospice enrollment and patient death. Uncertainty theory provided a framework for analysis. Diaries were transcribed, analyzed deductively and inductively, and organized thematically. Uncertainty in day-to-day experiences was an important driver of HCC burden and unmet needs. Unmet needs included unclear/unmet expectations regarding hospice care team support; not understanding the extent of HCC role and involvement; and communication challenges with hospice team members. Sources of HCCs' burden were dissonance between how they "should" feel and how they actually felt; feeling alone/having no outlet to express feelings; concerns about their own health and subsequent patient impact; and feeling helpless/occupying a liminal space. Uncertainty surrounding HCCs' experiences encompassed interactions with hospice care teams and the nature of end-of-life caregiving with symptom management, the dying process, and the HCC role. Hospice care teams can respond to uncertainty through assessment, understanding, and recognition of the daily context of HCCs.

Home Hospice Family Caregivers' Use of Audio Diaries and Reported Prevalence of Patient and Caregiver Symptoms

CONTEXT

Family caregivers are essential to home hospice care for patients with advanced cancer, including reporting patient symptoms to hospice providers for follow-up. Hospice caregiving can also impact personal well-being.

OBJECTIVES

1) Assess home hospice caregivers' use of prospective, longitudinal audio diaries tracking patient and caregiver wellbeing; 2) Explore how patient-focused vs. caregiver-focused diary prompts perform; 3) Examine the prevalence of interactive voice response (IVR)-tracked symptoms and whether diaries revealed additional symptoms.

METHODS

Caregivers (N=102) were asked to report patient and caregiver symptoms via daily IVR calls and could record optional diaries responding to patient-focused or caregiver-focused prompts. Diaries were transcribed, classified by presence/absence of new information, and compared by prompt type. Content coding for IVR-tracked symptoms and inductive coding for additional symptoms were summarized by frequency counts and exemplary quotes.

RESULTS

Sixty-nine percent of participants (n=70) recorded diaries, and of these 72.86% (n=51) recorded ≥ one new-information diary. The median recording length was 53.00 seconds (SD=53.36). Participants responding to the caregiver-focused prompt (n=33) recorded more diaries than those in the patient-focused group (n=37; U=437.500, P=0.04. Most prevalent IVR-tracked symptoms were patient fatigue/weakness (26.54% of symptoms mentioned) and pain (23.08%), and caregiver anxiety/nervousness (47.51%) and fatigue (22.10%). The most prevalent additional symptoms were patient increasing sleepiness/sleeping (26.32%) and breathing difficulties (24.32%), and negative caregiver emotions (e.g., guilt, resentment, anger; 29.17%).

CONCLUSION

Prospective audio diaries offer a viable avenue for communicating symptoms and support needs. Future research will focus on leveraging longitudinal data for developing focused and tailored caregiver support interventions.

The Burden of Having to Wonder: Minority Stress Experiences of LGBTQ+ Hospice Family Caregivers

Home hospice care relies heavily on informal caregivers, often patients’ family and close others. Hospice family caregivers report stress, burden, and unmet support needs associated with poor health and bereavement outcomes. These outcomes are sensitive to the quality of interactions with professional hospice providers, especially for historically marginalized groups, yet little research examines experiences of LGBTQ+ hospice family caregivers. Informed by minority stress theory, we conducted in-depth interviews with LGBTQ+ home hospice family caregivers across the U.S. (N=20). Participants reported demographics and described their caregiving experiences including interactions with hospice providers. Interviews were audio-recorded, transcribed, and content-analyzed. Participants were mostly white (n=15, 75%), non-Hispanic (n=19, 95%), cisgender (n=19, 95%), gender binary (n=19, 95%), lesbian (n=10, 50%), women (n=12, 60%); average age was 52.3 (range 25-67, SD=13.84). Along with known end-of-life caregiving stressors, participants experienced minority stress that complicated caregiver-provider communication. Distal stressors included lack of LGBTQ+ competent resources, inadequate legal protections, providers’ assumptions about relationships, and difficult dynamics with unaccepting relatives. Proximal stressors included perceived risks of disclosure, expectation of poor treatment, feeling the need to modify presentation of self or home, and wondering whether negative provider interactions were due to being LGBTQ+. This generated a background level of uncertainty, caution, and concern that was particularly distressing in the home setting. Minority stress affects LGBTQ+ people across the lifespan and generates added burdens and support needs for hospice family caregivers. Providers who understand these effects are better positioned to deliver safe, effective care to all families at end of life.

Results from a prospective study of individuals' symptoms and patient activation after hepatitis C treatment

The treatment of the hepatitis C virus has been revolutionized by the discovery of direct-acting antiviral medications, which offer more effective treatment with fewer potential side effects. Few studies have examined changes in patient-reported outcomes in individuals undergoing treatment for the hepatitis C virus in the immediate time period after the first treatment (within 1 month). This study is one of the first to use quantitative and qualitative methods to investigate changes in quality of life, patient activation, and symptom burden in adults undergoing treatment for hepatitis C virus with direct-acting antiviral medications. Seventy-three patients were followed in a prospective, longitudinal mixed-methods design. Changes pre and posttreatment in quality of life, patient activation, and symptom burden were very small in magnitude when looking across the entire sample. However, patients with lower self-reported health at baseline reported improved physical and psychological functioning 1-month posttreatment. Patients with higher self-reported health at baseline reported decreased general health posttreatment, although these effects were small. Qualitative results suggested that most patients found symptoms to be manageable despite experiencing both psychological and physical symptoms during treatment. We also found that 25% of patients had low levels of patient activation and may lack the basic knowledge and confidence to be an active participant in their health care. These findings suggest that patients may benefit from tailored information based on current health status about what to expect during and immediately after beginning direct-acting antiviral medication treatment.

Living With Hepatocellular Carcinoma Near the End of Life: Family Caregivers' Perspectives

PURPOSE/OBJECTIVES

To explore family caregivers' perspectives of caring for patients with terminal hepatocellular carcinoma (HCC) as patients approached the end of life.
.

RESEARCH APPROACH

Longitudinal, qualitative descriptive design.
.

SETTING

Oregon Health and Science University in Portland and Veterans Affairs Portland Health Care System in Oregon.
.

PARTICIPANTS

13 family caregivers with a mean age of 56 years (range = 22-68 years). The majority of family caregivers were female (n = 10) and identified as White (n = 11).
.

METHODOLOGIC APPROACH

Interview data were collected from family caregivers once a month for as many as six months, for a total of 39 interviews. Data were analyzed using conventional content analysis.
.

FINDINGS

Five core categories and nine subcategories were identified. From the time of the terminal diagnosis to the end of life, family caregivers felt unprepared, uncertain, and in need of information. They struggled with whether symptoms were HCC- or cirrhosis-related.
.

INTERPRETATION

Nurses can support family caregivers by eliciting their knowledge and concerns, and attending to symptom presentation and interpretation and to treatment challenges. Understanding challenges caregivers experience is crucial for developing interventions that address their desire for information, support, and help along the HCC disease trajectory.
.

IMPLICATIONS FOR NURSING

Nurses play a critical role in preparing caregivers to understand the importance of pain assessment and management and early referral to palliative care.

Caring to Learn and Learning to Care

The increasing numbers of aging and chronically ill prisoners incarcerated in Western nations is well-documented, as is the growing need for prison-based palliative and end-of-life care. Less often discussed is specifically how end-of-life care can and should be provided, by whom, and with what resources. One strategy incorporates prisoner volunteers into end-of-life services within a peer-care program. This article reports on one such program based on focused ethnographic study including in-depth interviews with inmate hospice volunteers, nursing staff, and corrections officers working in the hospice program. We describe how inmate volunteers learn hospice care through formal education and training, supervised practice, guidance from more experienced inmates, and support from correctional staff. We discuss how emergent values of mentorship and stewardship are seen by volunteers and staff as integral to prison hospice sustainability and discuss implications of this volunteer-centric model for response-ability for the end-of-life care of prisoners.

Essential Elements of an Effective Prison Hospice Program

As the number of prison inmates facing end-stage chronic illness grows, more prisons across the U.S. must address the need for end-of-life care. Many will likely need to develop a plan with potentially limited resources and external support. This case study presents one long-running model of care, the Louisiana State Penitentiary Prison Hospice Program. Based on field observations and in-depth interviews with hospice staff, inmate volunteers and corrections officers, we identify five essential elements that have contributed to the long-term operation of this program: patient-centered care, an inmate volunteer model, safety and security, shared values, and teamwork. We describe key characteristics of each of these elements, discuss how they align with earlier recommendations and research, and show how their integration supports a sustained model of prison end-of-life care.

Family members’ perspectives of caring for patients with terminal hepatocellular carcinoma

323

Background: Hepatocellular carcinoma (HCC) is a growing problem worldwide and accounts for more than 700,000 deaths annually. There is no curative treatment for those diagnosed with terminal HCC. This group of patients differs from other populations with liver disease or cancer due to the combined disease processes of cancer and liver failure. Although family members often play an integral role in providing care, no study was found specifically examining family member experiences of caring for patients with terminal HCC. The aim of this study was to describe family members’ experiences and perceptions of providing care for patients with HCC as they near the end of life. Methods: This longitudinal, prospective pilot study described here presents the qualitative results of semi-structured in-person interviews with a convenience sub-sample of 13 family members conducted once a month for up to a 6-month period. The interview guide included questions about family member experiences of providing care for patients living with HCC and any current concerns of significance. Interview data were analyzed using conventional content analysis. Results: Analysis included a total of 39 family member interviews. Ten family members were female and three were male (mean age = 56 years, range = 22-68 years). Family members’ relationships to patients varied and included: spouses, siblings, adult children, parents, and ex-spouses. The analysis resulted in four major themes: perception of and response to terminal HCC diagnosis, HCC progression, symptom assessment and interpretation, and challenges of providing care. Findings were colored by complex relationships between family members and patients that changed or did not change as the disease progressed. Conclusions: This study contributes new knowledge to begin developing interventions that address family members’ need for support, help, and information as the disease progresses and at the end of life. Future research should include a larger sample size that is more ethnically and racially diverse, includes more male family members, and focuses on how care provided by family members may vary based on kinship, and relationship dynamics.

The power of the liver transplant waiting list: a case presentation

End-stage liver disease (ESLD), the final stage of chronic liver disease, is treated with liver transplant. Many patients have serious ESLD-related complications and are admitted to the intensive care unit for treatment. Such patients are temporarily unsuitable to undergo transplant surgery and are placed into a temporarily inactive category, "status 7," on the transplant waiting list. Status 7 patients account for about 15% of all patients on the list. To describe the experience of a status 7 patient on the liver transplant waiting list from the perspectives of family members, 38 hours of bedside observation of participants, 9 semistructured interviews with 6 family members, and 9 semistructured interviews with 8 health care professionals from nursing, medicine, and other health care disciplines were done. Data were analyzed via conventional content analysis. Family members' perspectives fit into 3 phases that correspond to the progression of the patient's clinical condition: dealing with crisis, confusion and frustration, and back on the road to transplant. All 3 phases related to 1 goal: getting the patient's status reactivated on the liver transplant waiting list. This case exposes the struggles that patients with ESLD and their families may go through during the status 7 period and could serve as a starting point for further examination of this period.

Living with hepatocellular carcinoma from the patient perspective: A longitudinal study

373

Background: Hepatocellular carcinoma (HCC) is a growing problem. For those diagnosed with terminal HCC, there is no curative treatment. Despite a high death rate, no longitudinal studies were found examining the illness experience of patients with HCC as they are approaching death. The aim of this study was to describe the experience of living with terminal HCC and how it may affect end of life care from the perspective of patients. Methods: This was a longitudinal, prospective mixed methods pilot study using quantitative and qualitative approaches. Semi-structured interviews were conducted with a convenience sub-sample of 14 patients with HCC once a month for a 6-month period. The interview guide included questions about living with HCC, pain and symptom management strategies, treatment decisions, and any current concerns of significance. Interview data were analyzed using qualitative description. Results: This poster reports on qualitative analysis of 45 interviews from the sub-sample. Eleven patients were male and 3 were female (mean age=61.5, range=54-68 years). Findings included 4 major themes: 1) illness perceptions, 2) uncertainty about treatments over time, 3) quality of life, and 4) coping strategies. Patients perceived HCC as isolating as compared to other cancers. Patients lacked information to prepare them for the journey ahead. They struggled with symptom management over time and chose to stop treatment, delay treatment in hope of improvement, or regretted starting treatment once underway. Conclusions: For patients, the impact of HCC and treatment side effects on quality of life was challenging and filled with uncertainty. From this first step, knowledge gained is serving as the foundation for a proposed larger scale study. The goal is to develop future interventions to address challenges (e.g., symptom management and treatment decision making) at the end of life for these understudied cancer patients.

To be Truly Alive

Some US prisons are meeting the growing need for end-of-life care through inmate volunteer programs, yet knowledge of the motivations of inmate caregivers is underdeveloped. This study explored the motivations of inmate hospice volunteers from across Louisiana State (n = 75) through an open-ended survey, a grounded theory approach to analysis, and comparison of responses by experience level and gender. Participants expressed complex motivations; Inter-related themes on personal growth, social responsibility and ethical service to vulnerable peers suggested that inmate caregivers experience an underlying process of personal and social transformation, from hospice as a source of positive self-identity to peer-caregiving as a foundation for community. Better understanding of inmate caregiver motivations and processes will help prisons devise effective and sustainable end of life peer-care programs.

Living with terminal hepatocellular carcinoma: The patient and family perspective

e20702

Background: Hepatocellular carcinoma (HCC) is a growing problem worldwide; incidence of HCC in the U.S. has increased from 1.4 to 2.4 per 100,000 primarily because of people infected by hepatitis B or C. For those diagnosed with intermediate-advanced or terminal HCC, there is no curative treatment, and duration of survival is typically one to two years. Despite a high death rate, no studies were found examining experiences of living with terminal HCC and how it may affect end of life care from perspectives of both patients and family members. Methods: This pilot study used a prospective, longitudinal descriptive design, and qualitative and quantitative methods (mixed methods). Interview and survey (symptoms, quality of life) data were collected once a month for a 6-month period from 20 patient-family member dyads. Two researchers independently coded transcribed interview data into synthesized themes using inductive analysis, and met regularly to establish consensus on coding disagreements. Results: This poster reports on interview data from a convenience sub-sample of 14 patient-family member dyads. The interview data set comprised 56 interviews (14 conducted with patients, 11 with family members, and 31 with patient-family member dyads). Of the 14 patients, 11 were male and 3 were female (mean age=61.5, range=54-68 years). Of the 14 family members, 4 were male and 10 were female (mean age=57.4, range=22-68 years). Eight patients died during the study period. Findings from patient-family member dyad interviews included 5 major themes: 1) comparing diseases—differences and similarities between HCC and other types of illnesses/cancers (e.g., breast cancer), 2) uncertainty about treatments over time, 3) symptom management, 4) lack of support, and 5) family member caregiving struggles. Differences were found between interviews conducted with patients only and family members only, including perceived challenges in patient-family member relationships. Conclusions: From this first step, knowledge gained will serve as the foundation for a larger scale study and test of future interventions to address challenges (e.g., symptom management, caregiver burden) at the end of life for these cancer patients and their family members.

Life-sustaining treatment decisions in the ICU for patients with ESLD: a prospective investigation

We conducted a prospective study in the ICU of life-sustaining treatment and comfort care decisions over time in patients with end-stage liver disease (ESLD) from the perspectives of patients, family members, and healthcare professionals. Six patients with ESLD, 19 family members, and 122 professionals participated. The overarching theme describing the decision-making process was "on the train." Four sub-themes positioned patients and family members as passengers with limited control, unable to fully understand the decision-making process. Findings suggest that including patients and family members in non-immediate life-saving decisions and verifying early on their understanding may help to improve the decision-making process.