Surrogate health care decision making is often a challenge for everyone involved. In the case of incapacitated patients, family members, nurses, health care providers, and other members of the health care team often grapple with determining the most appropriate clinical course of action. For these difficult patient scenarios, the expertise of clinical ethics consultants is sought to assist with complex health care decision making. Clinical ethics consultation is designed to provide a more objective “outside” opinion and offer advice to the patient, family, and entire care team to support and guide decisions. Nurses are well positioned to initiate assistance from Clinical Ethics Consult Services in support of patient and family advocacy. This article presents a case analysis based on the Stakeholder, Facts, Norms, and Options Framework to analyze the best interest course of action for Mr K., a patient diagnosed with abdominal pain due to end-stage liver cirrhosis and who lacks decisional capacity in regard to his own treatment decision making. The case analysis highlights specific examples of how nurses can provide information, facilitate discussion, and otherwise support patients and families to achieve best interest outcomes.
Les personnes hébergées en centre d'hébergement et de soins de longue durée (CHSLD) présentent des problèmes de santé complexes. Les infirmières qui oeuvrent dans ce milieu doivent désormais les accompagner dans les différentes transitions, allant de leur admission jusqu'aux soins palliatifs et de fin de vie. Les soins palliatifs offerts en CHSLD font face à une augmentation importante des taux de décès, ainsi qu'à la nécessité d'optimiser les compétences des infirmières pour répondre aux besoins des personnes qui y sont hébergées. La pratique réflexive (PR) en groupe apparaît comme une approche novatrice dont les résultats semblent positifs pour le développement des compétences professionnelles. A notre connaissance, aucune étude ne s'est intéressée à la PR dans un contexte de soins palliatifs en CHSLD. La présente étude vise donc à évaluer l'influence d'une intervention de PR en groupe sur la perception de compétence en soins palliatifs des infirmières (PCISP) en CHSLD.
Purpose: Burnout in nursing is a global phenomenon. Caring for dying patients could increase nurses' death anxiety. However, minimal information about oncology nurses' burnout and attitudes towards death in Chinese culture has been reported. This study aims to assess Chinese oncology nurses’ burnout, and its relationship with attitudes towards death.
Method: A cross-sectional design was used. A total of 279 oncology nurses from a cancer hospital in northern China were recruited using convenience sampling, and completed a survey containing a demographic form, the Death Attitudes Profile Scale and the Maslach Burnout Inventory. Descriptive statistics, independent t-test and one-way ANOVA, Pearson correlation analysis and multiple regression analysis were conducted to analyze data.
Results: An average of 73.1%–86.9% of oncology nurses reported moderate to high levels of burnout. Specifically, 48.7%, 45.4% and 65.1% of oncology nurses reported high levels of emotional exhaustion, depersonalization and personal accomplishment, respectively. Multiple regression analysis showed that fear of death, escape acceptance, younger age and participation of death education/training were significantly associated with emotional exhaustion ( p < 0.01), accounting for 22.0% of the variance; fear of death, escape acceptance, and neutral acceptance in total explained 17.8% of depersonalization; fear of death, escape acceptance and neutral acceptance accounted for 8.5% of personal accomplishment.
Conclusions: Oncology nurses with more positive attitudes towards death experience less burnout. Death education and death related training including discussion of personal attitudes towards death should be part of nursing education programs, which would in turn prevent oncology nurses from burnout.
Studies have shown that registered nurses are inadequately prepared to care for patients requiring hospice and palliative care. Reasons include inadequate curriculum, along with a lack of structured education related to hospice/palliative care and symptom management, which includes inadequate education on delivering home-based hospice/palliative case management. Challenges at the Southwestern Hospice Organization are consistent with industry standards, evidenced by a high level of afterhours triage phone calls related to ineffective case management setup and delivery upon patient admission to hospice service. Many of these triage inquires could be prevented with improved registered nurse case management education and subsequent execution. Through analyzing Southwestern Hospice Organization afterhours triage phone data, a deficiency in effective patient case management setup and delivery was defined. Best practices in hospice/palliative case management were then identified, and a quality improvement plan in the form of a nurse driven, hands-on, home hospice/palliative case management simulation was generated. Quality improvement for patient case management at the Southwestern Hospice Organization was the end goal.
BACKGROUND: With increasing support for the integration of palliative care and standard oncology, communication training programs are needed to teach oncology nurses and other providers about palliative care communication.
OBJECTIVES: This study reports on the outcomes of COMFORTTM SM Communication for Oncology Nurses, a train-the-trainer communication course to educate oncology nurses about palliative care communication and improve patient-centered communication and cancer care.
METHODS: 355 oncology nurses attended the two-day course. This study used 6- and 12-month follow-up data from nurses who provided feedback on the progress of these goals.
FINDINGS: Nurses taught an additional 9,720 oncology providers, conducted needs assessments of communication processes, and initiated institutionwide palliative care communication training. Barriers to completing outcome goals included a lack of institutional support, specifically an absence of leadership, financial backing, and dedicated time.
This study aimed to evaluate nurses’ experiences and factors related to their attitudes regarding discussions of do-not-resuscitate (DNR) and withdrawal of life-sustaining treatment (LST) with patients and their families. A cross-sectional survey was conducted in a tertiary hospital in Taiwan. Nurses aged = 20 years who were in charge of acute inpatient care were randomly recruited. A semi-structured questionnaire was used to evaluate participants’ experiences and attitudes regarding discussions of DNR and LST withdrawal for terminal patients. Logistic regression with adjustment for covariates was used to analyze factors related to participants’ attitudes toward discussions about DNR and LST withdrawal with patients and families in the future care of terminal patients. The participants were 132 nurses. They had significantly more discussions about DNR and LST withdrawal with patients’ families than with patients. Regression analysis showed that participants who had past experiences in actively initiating DNR discussions with patients or patients’ families were significantly more likely to discuss DNR with patients in the future care of terminal patients, but participants aged 40.0 to 60.0 years were significantly less likely to have DNR discussions than those aged 20.0 to 29.9 years. Experiences of actively initiated DNR or LST discussions with patients’ families were significantly more likely to discuss DNR with patients’ families, but those aged 40.0 to 60.0 years were also significantly less likely to have DNR discussions than those aged 20.0 to 29.9 years. Experience in actively initiating discussions about LST withdrawal with patients’ families, being male, and possessing an education level higher than university were significantly related to LST withdrawal discussions with terminal patients or their families in the future. In conclusion, there need to be more discussions about DNR and LST withdrawal with patients. To protect patients’ autonomy and their rights to make decisions about their DNR and LST, measures are needed to facilitate DNR and LST discussions with patients to ensure better end-of-life care
Objectives: Decision-making on artificial nutrition and hydration for patients terminally ill with cancer can be influenced by nurses' knowledge, attitudes, and behavioral intentions. A comprehensive 57-item questionnaire including six sections on the knowledge, attitudes, and behavioral intentions in providing artificial nutrition and hydration to patients terminally ill with cancer has been developed and used in Taiwan. However, the questionnaire needs further psychometric testing and adaptation for other cultures. This study aimed to cross-culturally adapt the questionnaire within the Italian cultural context and test its psychometric properties.
Methods: The questionnaire was translated into Italian and cross-culturally adapted per the recommendations by Beaton. A panel of 10 experts assessed content validity. A multicenter cross-sectional study was conducted with 411 nurses to test its psychometric properties. Dimensionality and construct validity were assessed through exploratory and confirmatory factor analyses. Reliability was estimated by composite and traditional methods, such as the Kuder Richardson formula-20 and Cronbach's a coefficients.
Results: The overall content validity index was 0.85. A confirmatory factor analysis was conducted for the knowledge section and the four attitudes sections. A preliminary analysis for the behavioral intentions section yielded non acceptable results. The internal consistency of the scales was adequate (range, 0.64-0.93).
Conclusions: This study constituted a notable advancement in the psychometric testing of the tool, and provides evidence that the Italian version of the questionnaire has acceptable psychometric characteristics for the sections on knowledge and attitudes.
Objectives: A dementia nurse specialist (DNS) is expected to improve the quality of care and support to people with dementia nearing, and at, the end of life (EoL) by facilitating some key features of care. The aim of this study was to estimate willingness-to-pay (WTP) values from the general public perspective, for the different levels of support that the DNS can provide.
Methods: Contingent valuation methods were used to elicit the maximum WTP for scenarios describing different types of support provided by the DNS for EoL care in dementia. In a general population online survey, 1002 participants aged 18 years or more sampled from the United Kingdom provided valuations. Five scenarios were valued with mean WTP value calculated for each scenario along with the relationship between mean WTP and participant characteristics.
Results: The mean WTP varied across scenarios with higher values for the scenarios offering more features. Participants with some experience of dementia were willing to pay more compared with those with no experience. WTP values were higher for high-income groups compared with the lowest income level (P < .05). There was no evidence to suggest that respondent characteristics such as age, gender, family size, health utility or education status influenced the WTP values.
Conclusion: The general population values the anticipated improvement in dementia care provided by a DNS. This study will help inform judgements on interventions to improve the quality of EoL care.
Using the Ministry of Health, Labour and Welfare national data on perspectives toward medical care at the end of life, this study examined the current status of engagement in advance care planning (ACP) activities among physicians and nurses in Japan and associated factors. Only 28.7% of physicians and 27.6% of nurses answered that they were engaging their patients/clients in ACP. Multinomial regression analysis revealed that more frequent involvement in caring for dying patients was associated with ACP engagement for both physicians and nurses. Increased years of clinical practice experience and working in a hospital were associated with decreased likelihood of nurses' ACP engagement. Completion of training designed to promote patient self-determination at the end of life was associated with both physicians' and nurses' ACP engagement. It is recommended that health care professionals be encouraged to complete such training to promote patients' autonomy through ACP.
BACKGROUND: Advance care planning (ACP) defines end-of-life care in accordance with the patients' preferences. It is highly important during mental and/or physical deterioration, which prevents patients from expressing their wishes. Despite various attempts worldwide to promote the issue, it is not well established, suggesting various challenges in the implementation of the process in the medical system. The current study aimed to evaluate the perception of Israeli oncology staff members regarding the process.
METHODS: Physicians and nurses from a division of oncology participated in the study. They completed the study's questionnaires, which included quantitative items regarding staff and patients' motives and barriers, as well as qualitative questions to better evaluate their understanding regarding the process.
RESULTS: According to staff members, the optimal time to complete the forms is during the final stages of the disease. Making the right medical decisions and avoiding unnecessary medical procedures were rated as the main motives for patients in the process. The communication factor was perceived as the main barrier for patients, as well as the main motive and barrier for staff. The central role of communication was demonstrated in the qualitative section as well. Various differences were demonstrated between staff members who talked with patients about ACP and those who did not.
CONCLUSION: The study demonstrated the central role of communication in the process of ACP from the staff's perception. This highlights the need to further promote training programs for staff members to establish better interactions and communication skills when dealing with end-of-life issues.
BACKGROUND: The provision of appropriate end of life care for patients who have different life experiences, beliefs, value systems, religions, languages, and notions of healthcare, can be difficult and stressful for the nurse. To date, research has focused predominately on nurses' experiences of end of life care for the Muslim patient who is an immigrant in another country.
OBJECTIVES: To critically review the literature related to the lived experiences of non-Muslim expatriate nurses providing end of life care for Muslim patients in their home country.
DESIGN: Integrative Literature Review DATA SOURCES: Comprehensive online search of Library Databases: Ovid, CINAHL, EBSCOHost; MEDLINE; Science Citation Index Expanded; PubMED; Web of Science; PROQUEST, and Scopus.
REVIEW METHODS: An integrative review of literature published within the dates January 2000 - July 2017. Included articles were published in the English language, peer reviewed/refereed, and focused on nurses' experiences. Both qualitative and mixed method studies describing the experience of non-Muslim nurses providing nursing care to Muslim patients in a country that was predominately Muslim were included.
RESULTS: Initially 74 articles were found of which nine met the inclusion criteria. Research has been conducted predominantly within the Kingdom of Saudi Arabia, with one article from Bahrain and one other jointly from Kingdom of Saudi Arabia and the United Arab Emirates. The research indicates that expatriate nurses view themselves as powerless patient advocates, are hindered by the nurse-patient-family-physician quadriad structure, language and differing beliefs about communicating death, and negotiating culturally safe care is emotionally challenging.
CONCLUSION: This review highlights that the stressors associated with misalignment of expectations cause emotional and physical distress for the nurses. When nurses were focused on clinical care, they were unable to accommodate cultural practices that were important to the patient and family, contributing to increasing stress. Researchers have sought to capture this distress and make some sense of its impact. How nurses can provide culturally safe care, in countries with cultural practices quite different from their own, bears further investigation.
AIMS AND OBJECTIVES: To assess nurses' perceptions of what constitutes optimal end-of-life (EOL) care in hospital and evaluate nurses' perceived barriers to EOL care delivery.
BACKGROUND: Care of dying patients is common in hospitals. However, little is known about the important elements of and barriers to optimal EOL care from key service providers' perspective, which is crucial for quality EOL care in hospital settings.
METHOD: This is a cross-sectional survey. Nurses practicing in hospitals recruited by convenience sampling completed self-report survey questionnaires. STROBE checklist was used in study reporting.
RESULTS: One-hundred-and-seventy-five nurses participated in the survey. The majority (70%) had experience in caring for dying patients. The five most highly perceived factors constituting optimal EOL care included: 'families know and follow patient's EOL wishes'; 'patients emotional concerns identified and managed well'; 'patients participating in decision-making'; 'EOL care documents stored well and easily accessed'; and 'provide private rooms and unlimited visiting hours for families of dying patients'. Top five barriers were 'nurses and doctors being too busy'; 'insufficient private room/space'; 'nurses have limited training in EOL care'; and 'families have unrealistic expectations of patient's prognosis'. Multivariate regression analysis identified that nurses without experience in caring for dying patients reported a significantly higher number of perceived barriers towards EOL care (p = .012). Those with post-graduate degree training reported significantly fewer perceived barriers (p = .007).
CONCLUSION: Findings identified essential elements for optimal hospital EOL care not only involving patients and families in EOL decision and care, but also documentation and environmental issues in the healthcare system level and the needs for strengthening manpower and expertise at palliative care policy level.
RELEVANCE TO CLINICAL PRACTICE: This study revealed quantitative data to inform health service managers and policy makers in terms of training and service development/ re-design for EOL care in hospital settings.
Interprofessional shadowing, whereby medical students take on the role of another profession, is an effective interprofessional education (IPE) method to promote interprofessional teamwork. Palliative care is an ideal setting for IPE as multidisciplinary teams work together to deliver holistic patient care. This brief report explores junior doctors' experiences in shadowing nurses to provide care to patients in a hospice setting in New Zealand. We conducted semi-structured interviews with six participants to find out the impact that this shadowing experience had on their professional development and feasibility of incorporating this activity into the undergraduate medical curriculum. Inductive thematic analysis revealed that shadowing a nurse for two days increased participants' awareness of the nursing role and gave them the opportunity to develop a personal relationship with their patients, both of which made participants actively reflect on the value of IPE and the way they practice medicine. Participants considered the palliative care setting as conducive to IPE and saw the value of incorporating interprofessional shadowing into the undergraduate medical curriculum.
The mark of a true profession is the ability to self-regulate. As such, advanced practice registered nurses (APRNs) are challenged by their professional organisations to participate in self-evaluation and peer review. Peer review is a method for evaluating the care provided by the APRN to both ensure quality nursing care and promote professional growth. Despite guidelines to participate in a formal peer-review process, there is little information within the nursing profession on how to accomplish peer review. A comprehensive literature review failed to provide a framework for peer review that is practice focused, fosters a learning environment and encompasses the thought process and clinical decision-making of the palliative care advanced practice nurse. A group of palliative care APRNs set out to create a process that encompassed the breadth of clinical decision-making in palliative care advanced nursing practice. Using the eight domains of palliative care, a narrative case review structure was created. The resulting process both assisted the APRNs in professional growth and provided timely feedback for the annual performance evaluation.
The aim of the present study is to validate the Self-Efficacy in Palliative Care Scale (SEPC) in Spanish nursing professionals and students, to describe their levels of self-efficacy, and to determine the influencing factors. A validation study and a cross-sectional descriptive study were carried out, with the data analysed using contrast tests and multiple linear regression; 552 nurses and 440 nursing students participated. The Spanish version consists of 23 items and has a high degree of reliability (a = 0.944). Confirmatory factor analysis revealed one additional factor (i.e., management of psychosocial and spiritual aspects) in comparison to the original scale. Contrast tests revealed that the mean SEPC score was higher in professionals than in students (p < 0.001) and that the professionals who had higher levels of self-efficacy were older (p < 0.001), had more previous training (p < 0.001), and had more experience in end-of-life care (p = 0.001). The linear analysis results confirm a significant association between age and previous training in end-of-life care. The Spanish version of the SEPC is a reliable tool for both nursing professionals and students. The level of self-efficacy of both groups is moderate and is influenced by age, experience, and training in end-of-life care.
This study aims to investigate the relationship between death anxiety of the Turkish nurses and their attitudes toward the dying patient. This study involved 203 nurses who were working at a university hospital. The data were collected using “Nurse Information Form” (which was prepared by the authors of this research), “Thorson-Powell Death Anxiety Scale,” and “Attitude Scale about Euthanasia, Death, and Dying Patient.” There was a positive correlation between death anxiety and dying patient avoidance behavior and euthanasia score (p < .05). The findings showed that nurses, death anxiety, and death scores were high in the loss of a close relatives (p < .05). Our findings suggest that the situation of the dying patients and their families and also nurses should be improved. Thus, special psychological education/training should be given to the nurses to deal with death anxiety and their attitude to the dying patient.
AIMS AND OBJECTIVES: To examine the content and reported psychometric properties of instruments for assessing nurses´ palliative care knowledge and skills in specialised healthcare units.
BACKGROUND: Knowledge of palliative care, and competence in the delivery of care, are essential. Assessment of competence is an important means of evaluating the knowledge and skills of practitioners in order to improve the quality of care provided for patients and their families.
DESIGN: An integrative review.
METHODS: A systematic literature search was conducted in November 2018 in five databases: CINAHL, PubMed (Medline), Cochrane, Scopus and Web of Science. The quality assessment was conducted using the Joanna Briggs Institute´s (JBI) Checklist for Analytical Cross-Sectional Studies. The data was analysed using content analysis. PRISMA guidelines were followed to ensure explicit reporting.
RESULTS: Overall, 5,413 studies were identified and 23 met the inclusion criteria. Nurses' knowledge and skills, as assessed by the instruments, were: 1) care for the patient, 2) care for the patient´s family and 3) professional requirements. Ten instruments were identified assessing nurses' knowledge and skills through knowledge tests and skill-evaluation self-tests. The psychometric properties of the instruments were reported to varying degrees, mainly focusing on internal consistency and content validation.
CONCLUSIONS: Nurses´ knowledge and skills were seen to contribute to the holistic care of the patient and his or her family, and the possession of adequate information and skills is essential when dealing with death and dying. The instruments are commonly available and potentially reliable, although reliability must be determined with caution, so validation studies in other cultures are recommended.
RELEVANCE TO CLINICAL PRACTICE: These results could be utilised to improve the quality of palliative care by evaluating the knowledge and skills of nursing staff, or when considering the needs of palliative care education.
This study has been conducted with the purpose of identifying the perceptions of palliative nurses about death and determining palliative care practices. We conducted qualitative interviews with 23 palliative care nurses in Turkey. Content analysis was used in the evaluation of the data. Three themes have been identified about perception of death. Furthermore, three themes have been identified about palliative care practices. It was concluded that the palliative nurses perceive death as a natural and inevitable process and that as long as their working period increases, they become desensitized. It was identified that the participants generally perform the following procedures in palliative care practices.
Infirmier à l'Ehpad de Chomérac depuis 2011, j'ai la chance d'avoir été mis par mon établissement à disposition de l'équipe mobile de soins palliatifs du centre hospitalier de Privas. Je parle de chance car je suis bien conscient d'occuper une position très privilégiée : en effet, depuis août 2017, j'ai pu à la fois profiter du caractère extrêmement enrichissant de l'équipe mobile (à mi-temps) tout en continuant à prendre soin de "mes" résidents.
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The use of multidimensional scales for assessing fear of death among nursing students can assist in teaching and evaluating the effectiveness of targeted training in thanatology. Research has demonstrated good psychometric characteristics of the Czech version of the Collett–Lester Fear of Death Scale (CL-FODS). It was applied to nursing students (N = 256), who reported as their biggest fear the process of their own dying. Greater fear of death and dying was found in students who had no experience of the dying and death of a loved one. Good internal consistency was achieved for the four subscales of the Czech CL-FODS.