BACKGROUND: In the last two decades, nursing authors have published ethical analyses of palliative sedation-an end-of-life care practice that also receives significant attention in the broader medical and bioethics literature. This nursing literature is important, because it contributes to disciplinary understandings about nursing values and responsibilities in end-of-life care.
RESEARCH AIM: The purpose of this project is to review existing nursing ethics literature about palliative sedation, and to analyze how nurses' moral identities are portrayed within this literature.
RESEARCH DESIGN: We reviewed discussion papers, written by nurses about the ethics of palliative sedation, which were cited in MEDLINE, CINAHL, Nursing and Allied Health, or Philosopher's Index (search date March 2018). Twenty-one papers met selection criteria. We performed a comprehensive review and analysis (using the Qualitative Analysis Guide of Leuven), of the values, responsibilities, and relationships reflected in authors' portrayal of the nursing role.
FINDINGS: Two different tones are apparent in the extant nursing ethics literature. One is educational, while the other is critically reflective. Irrespective of tone, all authors agree on the alleviation of suffering as a fundamental nursing responsibility. However, they differ in their analysis of this responsibility in relation to other values in end-of-life care, including those that depend on consciousness. Finally, authors emphasize the importance of subjective and experience-based understandings of palliative sedation, which they argue as depending on nurses' proximity to patients and families in end-of-life care.
DISCUSSION AND CONCLUSION: Based on our findings, we develop three recommendations for future writing by nurses about palliative sedation. These relate to the responsibility of recognizing how consciousness might matter in (some) peoples' moral experiences of death and dying, to the importance of moral reflectiveness in nursing practice, and to the value of a relational approach in conceptualizing the nursing ethics of palliative sedation.
BACKGROUND: Grieving and death rituals vary widely across cultures and are often influenced by geographical regions, religions, and local norms. Nursing rituals reflect the forms of cultural behaviour that assist in communicating traditional knowledge and practices. They help nurses maintain social order through cohesion and interaction.
AIM AND OBJECTIVES: Exploration of European and Middle Eastern intensive care nursing ceremonies and rituals surrounding care provided to patients after death has been carried out. The key question researchers asked was "Can you describe your practice of caring for a patient who has died?"
DESIGN: Prospective qualitative thematic analysis.
METHODS: This study used a prospective qualitative thematic analysis investigating nursing practice and rituals when caring for patients who have died in intensive care. The interviews were conducted face-to-face with nurses consenting to be interviewed for research purposes. During the interviews, researchers noted sentences and topics, which they later classified into categories and subcategories. The interview settings were international and national conferences, workshops, meetings, and seminars over a 2-year period. Thematic analysis was performed. This analysis allowed the researchers to understand and make sense of collective meanings and experiences of participants.
RESULTS: A total of 23 interviews with critical care nurses from 16 countries in Europe and Middle East were conducted. Through reflective and meaningful analytical interpretation, two main themes (with subthemes) emerged: sacredness and dignity. More similarities than differences among the nurses' experiences were found. Rituals included, opening a window, lighting a candle, blessing the deceased, and bereaving with the family.
CONCLUSIONS: Post-death ritual reflects local guidelines regulating the handling of the deceased body, culturally approved expressions of mourning, and acts to perform at specific times following death. Nursing rituals expressed here demonstrated the dignity, wherein nurses show towards the deceased and relationships between deceased and bereaved.
RELEVANCE TO CLINICAL PRACTICE: The investigators perceived nursing culture, beliefs, ceremonies, and rituals surrounding caring for patients who have died to be creative, spiritual, meaningful, and relevant for nurses.
Background: Few studies have estimated planned home deaths compared to actual place of death in a general population or the longitudinal course of home nursing services and associations with place of death. We aimed to investigate trajectories of nursing services, potentially planned home deaths regardless of place of death; and associations of place of death with potentially planned home deaths and nursing service trajectories, by analyzing data from the last 90 days of life.
Methods: A retrospective longitudinal study with data from the Norwegian Cause of Death Registry and National registry for statistics on municipal healthcare services included all community-dwelling people who died in Norway 2012–2013 (n = 53,396). We used a group-based trajectory model to identify joint trajectories of home nursing (hours per week) and probability of a skilled nursing facility (SNF) stay, each of the 13 weeks leading up to death. An algorithm estimated potentially planned home deaths. We used a multinomial logistic regression model to estimate associations of place of death with potentially planned home deaths, trajectories of home nursing and short-term SNF.
Results: We identified four home nursing service trajectories: no (46.5%), accelerating (7.6%), decreasing (22.1%), and high (23.5%) home nursing; and four trajectories of the probability of a SNF stay: low (69.0%), intermediate (6.7%), escalating (15.9%), and increasing (8.4%) SNF. An estimated 24.0% of all deaths were potentially planned home deaths, of which a third occurred at home. Only high home nursing was associated with increased likelihood of a home death (adjusted relative risk ratio (aRRR) 1.29; CI 1.21–1.38). Following any trajectory with elevated probability of a SNF stay reduced the likelihood of a home death.
Conclusions: We estimated few potentially planned home deaths. Trajectories of home nursing hours and probability of SNF stays indicated possible effective palliative home nursing for some, but also missed opportunities of staying at home longer at the end-of-life. Continuity of care seems to be an important factor in palliative home care and home death.
Nurses play an essential role in providing compassionate evidence-based care at the end of life, yet many undergraduate students have limited opportunities to participate in end-of-life care experiences. Arts-based pedagogy has been explored as a strategy in nursing education that focuses on the affective domain of learning. The purpose of this qualitative narrative analysis was to explore the impact of an arts-based reflection assignment on student affective learning using artistic images depicting end-of-life scenarios. Student written narratives (n = 21) were analyzed using content analysis, and four themes emerged that described the components of affective learning in several areas.
The study examined the influence of training on first-year nursing department students’ attitudes on death and caring for dying patients. Utilizing the experimental model, the study sample consisted of 81 first-year students attending the nursing department of a university. Death Attitude Profile-Revised and Frommelt Attitude toward Care of the Dying Scale were used for data collection. Data analysis included means, standard deviation, and t test for related samples. Student attitudes toward death were measured as 146.43 (16.741) and 152.75 (15.132) for pre- and posttraining, respectively. Student attitudes toward caring for dying patients were established to be 103.02 (7.655) during pretraining period and 111.02 (10.359) at posttraining period. The difference between pre- and posttests for mean attitudes toward death and caring for the dying patient was statistically significant. Study results determined that training was effective in forming positive student attitudes toward death and caring for dying patients.
This study was conducted to evaluate the efficiency of a nursing support program developed in accordance with the Roy adaptation model that was applied in addition to routine nursing care during the treatment process of pregnant women for whom the medical termination decision. This study, which was conducted using a pretest–posttest design, was a prospective, single-blind, and randomized-controlled empirical study. In the experimental group, although the first and last assessment State Anxiety Inventory scores were higher than those in the control group after the medical termination nursing support program, there was no significant difference. Compared with the control group, there were positive differences in the Scale of Ways of Coping with Stress, Adaptation Assessment Form for Role Function Area, and physical complaints in the experimental group. At the follow-up assessment, the total Perinatal Grief Scale score was significantly higher than that in the control group.
OBJECTIVES: To understand the meaning attributed by the nurse to the management of nursing care to the person hospitalized due to clinical complications caused by AIDS; to analyze actions related to palliative care; and to construct a theoretical matrix regarding the management of nursing care.
METHOD: Qualitative, exploratory research, guided by the Grounded Theory. Seven nurses and ten nursing technicians were interviewed between May and September 2015, in a university hospital, located in Rio de Janeiro State, Brazil.
RESULTS: Five categories that covered the profile of the hospitalized person, palliative care, intervening conditions for care management, the need for professional qualification, and other aspects to better organize and manage care, including conflict management arose.
FINAL CONSIDERATIONS: The theoretical matrix values the quality of life, the need to understand the flow of care to avoid readmissions and not adherence to medications, requiring new research in the area, such as implementation.
Nursing students, who have been receiving the End-of-Life Nursing Education Consortium (ELNEC) Core training throughout their Bachelor of Science in Nursing program, have a unique perspective of the benefits of this training. In addition, they have insight as to where an online ELNEC module series specifically for undergraduate nursing students would best be integrated within the curriculum. This study used a mixed methods strategy to evaluate students' opinions on the placement of end-of-life care education within the curriculum and their experience of having received ELNEC training previously throughout their program. Senior-level nursing student opinions on the placement of the ELNEC modules within the curriculum were equally divided, with one-third suggesting placement at the sophomore level, one-third suggesting placement at the junior level, and one-third suggesting placement at the senior level. Students also offered a recommendation for an end-of-life care simulation integration into the Bachelor of Science in Nursing curriculum. Students who have been receiving ELNEC training integrated throughout the curriculum reported feeling comfortable with providing end-of-life care after graduation. Themes extracted from students' suggestions on improving end-of-life care education were as follows: (1) The quality and consistency of instruction needs to be enhanced, (2) palliative care education should be delivered using various methods, and (3) methods to assess education on palliative care should be improved. Students reported that ELNEC training helped them to gain insight into the key elements in palliative care, to understand the differences and similarities between palliative care and hospice, and to understand the nurse's role in palliative care and hospice.
In China, the development of palliative care is challenging because of limited available resources and rapidly increasing demands. The nurses' competence is a significant element in providing high-quality palliative care. This cross-sectional study aimed to describe the palliative care competence among oncology nurses and to examine the relationships between it and palliative care knowledge, attitudes, and workplace learning conditions. A total of 220 nurses with more than 6 months of experience and who worked in inpatient wards were invited to participate in this study. Four questionnaires were administered to collect data-the Palliative Care Quiz for Nurses, the Attitudes Toward Palliative Care Scale, the Workplace Learning Conditions scale, and the Palliative Care Nursing Self-competence Scale. The data were analyzed using descriptive statistics and Pearson correlations. The moderate level of competence was reported by 212 participants (response rate, 96.36%). The scores were lower in the aspects of competence such as spiritual care and ethical and legal issues. Competence was positively related to workplace learning conditions and knowledge but not attitudes. The results highlighted the necessity of improving the palliative care competence among oncology nurses. The optimization of learning conditions in the hospital is recommended to be a vital force in strengthening competence.
Primary palliative care education should be provided within prelicensure programs to maximize nurses’ preparation to care for patients with serious, life-limiting illness before entering professional practice settings. Curricula need to be assessed to identify current content integration across nursing programs. The specific aim of this feasibility study was to evaluate the effectiveness of a survey methodology to assess primary palliative care content integration within prelicensure nursing curricula in multiple programs. A secondary aim was to compare content integration across nursing programs. Faculty teaching in prelicensure courses at 3 accredited nursing programs were recruited to complete a 50-item curriculum assessment survey based on the End-of-Life Nursing Education Consortium Undergraduate Curriculum. Response rates were 73%, 26.7%, and 18.8%, respectively. All content areas were reported as being taught by at least 1 faculty member per institution. Lecture was the primary pedagogy to teach all End-of-Life Nursing Education Consortium Undergraduate content areas, followed by clinical conference/debriefing and simulation. Content was primarily taught in Critical Care, Maternity, Adult Health, Gerontology, and Fundamentals courses. The disparate response rates suggest that survey dissemination may prove ineffective for multisite curricula evaluation. Implications for nursing education and clinical practice will be discussed.
Background: An urgent need to improve palliative care in hospital has been identified. Moreover, service users consistently report care delivered by nurses in hospital as lacking compassion. Compassion is a fundamental component of nursing care and promoting compassionate care has been identified as a policy priority in many countries. To help address this within the hospital context, we recently completed research exploring bereaved family experiences of good end of life care in hospital. We found that family accounts of good care aligned with Nolan and Dewar's compassionate care framework and subsequently extended the framework to the bi-cultural context of Aotearoa, New Zealand.
Aims: In this discussion paper we explore synergies between our newly developed Kapakapa Manawa Framework: a bi-cultural approach to providing compassionate care at the end of life and the Fundamentals of Care. We argue that our framework can be used to support the implementation of the relational component of the Fundamentals of Care and the delivery of compassionate nursing practice in hospitals in Aotearoa, New Zealand.
Design: Discussion paper.
Methods: Review of relevant literature and construction of two vignettes describing good end of life care from the perspectives of bereaved family – one Maori and one non-Maori. The vignettes provide practical examples of how the values of the Kapakapa Manawa Framework can be enacted by nurses to provide compassionate care in alignment with the relationship component of the Fundamentals of Care.
Conclusions and relevance to clinical practice: Whilst the Kapakapa Manawa bi--cultural compassionate care framework has grown out of research conducted with people nearing the end of their lives, it has the potential to improve nursing care for all hospital inpatients. In addition, addressing the wider policy and health system factors detailed in the Fundamentals of Care will support its implementation in the clinical setting.
BACKGROUND: The need to provide care for the dying patient and his/her family may occur in every medical setting. Newly graduated nurses and physicians should therefore be prepared to deliver it at a high-quality level.
OBJECTIVES: To explore (a) the primary difficulties participants anticipate they will encounter whilst working with dying patients, (b) their interest in developing competencies in caring for dying patients, and (c) their interest in working in palliative/hospice settings or with dying patients in the future.
DESIGN: A cross-sectional study.
SETTINGS: A medical university in Poland.
PARTICIPANTS: Convenience sample of nursing (=112) and medical students (=101) at the end of their undergraduate education.
METHODS: Questionnaire distributed online and in hard-copy format.
RESULTS: Half of the participants anticipated experiencing various emotional and professional difficulties in caring for dying individuals, especially medical students. These difficulties pertained mostly the reaction of family members to the patient's death, addressing the psychological needs of the dying person, and coping with his/her own emotions when dealing with the patient's death. Students reported that working with dying patients could cause occupational stress - more so among medical students. The majority of them showed an interest in improving knowledge regarding palliative care and also in this case this was mostly true of medical rather than nursing students. However, more than half of the participants preferred avoiding work in palliative/hospice settings, with no differences between the two groups. Participants attributed this attitude to two factors: (a) the desire to avoid negative emotions and stress that could be triggered by dealing with death and dying; and (b) because they felt they lacked the required skills and personal abilities to handle such situations.
CONCLUSIONS: Undergraduate curricula that include strategies for coping with negative emotions associated with facing the process of death and dying should be developed. Interprofessional education should be encouraged, especially regarding the psychosocial aspects of end-of-life care.
Death and dying are natural phenomena embedded within complex political, cultural and social systems. Nurses often practice at the forefront of this process and have a fundamental role in caring for both patients and those close to them during the process of dying and following death. While nursing has a rich tradition in advancing the palliative and end-of-life care movement, new modes of care for patients with serious and irremediable medical conditions arise when assisted death is legalized in a particular jurisdiction. In early 2015, the Supreme Court of Canada released its landmark decision Carter v. Canada (Attorney General) ('Carter'), which legalized physician-assisted suicide in particular clinical situations. The new law provided the broad national framework for Medical Assistance in Dying (MAiD) in Canada but, once the law was passed, provincial and territorial governments and health professional regulatory bodies each had to undertake a process of developing policies, procedures and processes to guide MAiD-related practice specific to their jurisdiction. In this paper, we begin to examine the political ramifications and professional tensions arising from MAiD for nurses and nursing, focusing specifically upon the impacts for registered nurses. We identify how variations in the provincial and territorial literature and regulatory guidelines across Canada have given rise to role confusion and uncertainty among some registered nurses and how this may potentially impact patient care. We then continue to highlight the need for greater political activism among nurses to foster greater clarity in nursing roles in MAiD and to advocate for improved supports for patients and those close to them.
End-of-life care in the neonatal intensive care unit (NICU) is one of the most challenging practices for nurses. Negative emotions associated with moral distress often cause care to be incomplete or nurse disengagement. Emotional intelligence in nurses holds potential to address this issue, while improving patient outcomes. The purpose of this study was to critically appraise the evidence about emotional intelligence in nursing and to explore the relationship between emotional intelligence, moral distress in NICU nurses, end-of-life care, and other priority nurse and patient outcomes. A PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses)–structured integrative review was conducted, and CINAHL, Ovid, PubMed, and other databases were searched. Twelve studies were identified as relevant to this review after exclusion criteria were applied. Evidence supports the efficacy of emotional intelligence in bedside nurses as a method of improving key nurse and patient outcomes. Additionally, research suggests that emotional intelligence can be improved by training interventions. Clinical educators should integrate emotional intelligence concepts and strategies into staff training. Further research is recommended to validate previous findings in the NICU setting. Exploration of the relationship between emotional intelligence and moral distress in NICU nurses would provide a foundation for experimental designs to evaluate the effectiveness of emotional intelligence training interventions.
Nurses play an integral role in high-quality patient care. Thus, their skills in providing end-of-life care should be assessed and continually enhanced. Education intended to improve end-of-life skills must address the affective/emotional component of nursing care. Evidence demonstrates that emotional engagement and resilience among health care providers are correlated with improved quality outcomes and, conversely, that burnout and stress negatively affect patient safety. Addressing the emotional needs of health care providers is critical to improving quality throughout the health care system. An evidence-based workshop was implemented among direct care staff on a hospital-based palliative care unit, with the goal of fostering emotional engagement to improve staff perceptions and attitudes about caring for patients at or near the end of life. Although perceptions about quality of death were not affected by this intervention, there was a significant improvement in attitudes about end-of-life nursing care. Qualitative feedback also reflected appreciation for small group discussions and opportunities to debrief with peers away from the unit. This intervention reflected the value of emotional engagement in educational efforts to improve end-of-life nursing care.
This study developed an end-of-life (EOL) care nursing knowledge scale for Japanese geriatric nurses (ELNKS-JG) to measure nurse knowledge of EOL care for older adults. It also was used to evaluate the quality of The End-of-Life Nursing Education Consortium–Japan Geriatric. Participants were 1168 nurses employed in 32 institutions across Japan. The items of our measure were developed to cover 8 important topics: principles of EOL care for older adults; pain management; symptom management; ethics of care; cultural and spiritual considerations; communication; loss, grief, and bereavement; and caring for final days. The measure included 51 items with an overall Cronbach a coefficient of 0.87 and an intraclass correlation coefficient of 0.81. Our measure, the ELNKS-JG, was confirmed to have good internal consistency, test-retest reliability, content validity, and known-groups validity. This scale’s items included knowledge about noncancerous diseases, physical changes due to aging, family care, and multidisciplinary collaboration. The ELNKS-JG comprehensively measures a nurse’s knowledge of EOL care for older adults in any EOL setting. Furthermore, this scale can evaluate educational programs aimed at improving care quality and encouraging related activities in facilities that provide EOL care.
The experience of parental death concomitant with parental divorce occurs for 46% of Danish children and 50% of American children who lose a parent to death. This experience of loss and double bereavement compounds increased risk of mental health problems. The aim of this study was to explore nursing interventions for double bereaved children that promoted their well-being. A phenomenological-hermeneutic approach was used to conduct 20 interviews with nurses in family cancer care. Ricoeur's theoretical framework was followed with naïve reading, structural analysis, and critical interpretation, resulting in the formulation of a new model of nursing care for these children: the Divorced Family-Focused Care Model. Four themes were apparent: (a) collection of information about family structure, (b) assessment of support needs, (c) initiation of well-being support, and (d) coordination and follow-up focused on the child's well-being. The new intervention model has implications for health care education and implementation of health care policies.
Palliative care philosophy is based on a holistic approach to patients, but research shows that possibilities for living up to this philosophy seem limited by historical and administrative structures. From the nurse perspective, this article aims to explore nursing practice in specialised palliative homecare, and how it is influenced by organisational and cultural structures. Qualitative, semi-structured interviews with nine nurses were conducted, inspired by Bourdieu. The findings showed that nurses consolidate the doxa of medicine, including medical-professional values that configure a control-oriented, positivistic approach, supported by the organising policy for clinical practice. Hierarchically, nurses were positioned under doctors: medical rounds functioned as a structuring structure for their working day. They acted as medical assistants, and the prevailing medical logic seemed to make it difficult for nurses to meet their own humanistic ideals. Only short time slots allowed nurses to prioritise psychosocial needs of patients and relatives. Point-of-actions had high priority, added financial resources and ensured that budgets were allocated. Weekly visits made it possible for nurses to measure, control and govern patients' drugs and symptoms which was a necessity for their function as medical assistants. The findings challenge nurses to take on an ethical point of view, partly to ensure that patients and their families receive good palliative care focusing on more than medical issues and logic, and partly to strengthen the nurses' profession in the palliative field and help them implement palliative care philosophy in practice.
In June 2015, the Supreme Court of Canada struck down the Criminal Code's prohibition on assisted death. Just over a year later, the federal government crafted legislation to entrench medical assistance in dying (MAiD), the term used in Canada in place of physician-assisted death. Notably, Canada became the first country to allow nurse practitioners to act as assessors and providers, a result of a strong lobby by the Canadian Nurses Association. However, a legislated approach to assisted death has proven challenging in a number of areas. Although it facilitates a degree of accountability, precision and accessibility, it has also resulted in particular challenges negotiating the diverse perspectives of such a morally contentious act. One of these challenges is the tendency to conflate what is legal and what is moral in a modern liberal constitutionalism that places supreme value on autonomy and choice. Such a conflation tends to render invisible the legal and moral/ethical considerations necessary for nurses and nurse practitioners to remain ethical actors. In this paper, we introduce this conflation and then discuss the process of lawmaking in Canada, including the legalization of MAiD and the contributions of nursing to that legalization. We then engage in a hypothetical dialogue about the legal and moral/ethical implications of MAiD for nursing in Canada. We conclude with an appeal for morally sustainable workspaces that, when implementing MAiD, appropriately balance patient choices and nurses' moral well-being.
BACKGROUND: The need to provide quality end-of-life care is universally accepted. International research and policies encourage innovative ways that effective culturally appropriate care can be provided. Higher education institutions and practice settings are tasked with ensuring that nurse graduates have the knowledge, skills and insight to deliver person-centred end-of-life care.
RESEARCH AIMS AND OBJECTIVES: The aim was to explore student evaluation of end-of-life care learning within a three-year undergraduate adult nursing degree programme. Objectives were to assess student perceptions of the content and level of learning achieved, explore usefulness of learning, highlight areas that were most useful, and identify suggestions to improve learning.
DESIGN: A 3-year quantitative longitudinal design was used. A questionnaire containing open and closed questions was designed to incorporate the personal and professional learning strategies indicated by the Nursing and Midwifery Council (NMC) (2010).
SETTING AND PARTICIPANTS: The evaluation was completed at the same time point over a three-year period from April 2015–April 2017. The participants were year three student nurses, from 3 consecutive years, enrolled on a pre-registration adult nursing course at one university. There was a 66% response rate (n = 336).
METHODS: Participant information sheets and questionnaires were distributed and time to complete them facilitated. Responses from closed questions were coded and analysed using descriptive statistics (SPSS 24) and thematic analysis used for open questions.
RESULTS: Students expressed satisfaction with their learning, 88.7-97% of students reported a positive impact on their knowledge. They developed an understanding of the impact the nurse can have on the patient and family experience, reporting more confidence and competence in most aspects of end-of-life care. They noted improved ability to utilise this in their subsequent practice experience 88.1-97%.
CONCLUSIONS: Structured end-of-life care within the curriculum is essential to equip graduate nurses to provide effective evidence informed care. Planning should continue for curriculum development that encompasses person-centred end-of-life care across cultures.