Palliative care for patients with cancer: district nurses' experiences

AIM: This paper reports a study exploring district nurses' experiences of providing palliative care for patients with cancer and their families. BACKGROUND: There is an increasing demand for palliative care in the community, as many patients wish to die at home. District nurses are central to providing palliative care in the community, but there is a dearth of literature on district nurses' experiences in palliative care. METHOD: A Husserlian phenomenological approach was adopted with a purposive sample of 25 female district nurses. Data were collected using unstructured, tape-recorded interviews and analysed using Colaizzi's seven stages of data analysis. FINDINGS: Four themes were identified: the communication web; the family as an element of care; challenges for the district nurse in symptom management and the personal cost of caring. CONCLUSIONS: District nurses' experiences of providing palliative care to family units was challenging but rewarding. The emotive nature of the experience cannot be under-estimated, as many district nurses were touched by the varying situations. Whilst acknowledging the need to maintain an integrated approach to care, district nurses should be identified as the key workers in the complex situation of palliative care.     

District nurses’ role in palliative care provision: A realist review

Objectives

The aim of this review is to construct a detailed account of the role of the district nurse (generalist registered nurse providing nursing care in primarily home settings) in providing palliative care, to determine if and how district nursing care provides effective care to such patients at home, and to examine the utility of a realist review for the above purpose.

Design

Realist review of literature.

Data sources

Papers in English reporting aspects of the district nurse role in the provision of palliative care are included. Electronic databases (Ovid Medline, Cinnahl, British Nursing Index, Embase, PsycINFO and EBM reviews) were searched, supplemented by citation tracking and grey literature searches.

Review methods

Assumptions about district nursing practice with palliative care patients are derived from a range of sources. Reviewed papers are interrogated to support, refute or develop these statements.

Results

Forty six papers employing a range of research methods are incorporated into the review. Studies focus on district nurses, patients, family carers and other professionals and include work from a range of countries. Studies highlight the value district nurses place on palliative care provision, the importance of developing a relationship with patients, and the emotional difficulties of providing such care. District nurses have key skills in providing physical care and in coordinating the work of others, but struggle more with psychological aspects of care. District nurses report feeling undervalued, and express some reluctance to work with other health and social care professionals to provide care.

Conclusions

There is little in this synthesis to shed light on the outcomes of care or to explicitly guide practice. District nurses clearly articulate what they consider to be important, but research in this area is limited and needs to undergo a renaissance to examine what is important: namely what district nurses do in practice; what patients and family carers views are on what they do and do not do; and how district nurses can improve care outcomes. The inclusiveness of realist review works well for this field of study.     

Priority areas for clinical research in palliative care nursing

This report highlights a number of current research issues and concerns in palliative care nursing. The aim of the study was to identify high clinical nursing research priorities in palliative care, drawing on the expertise of nine (n = 9) clinical nurse consultants currently working in this specialty. The Delphi method was used to collect and process data in the study. Thirteen high research priorities emerged which have relevance for nursing practice, patient and family care in the hospice and community care setting. In the context of this study, the concept of high priority relates to research participant consensus on the most pressing nursing research problems which require investigation to improve clinical practice. Study findings provide direction for clinical research and continuing education in palliative care which may benefit expert nurses and their patients.     

Emphasizing terminal care as district nursing work: a helpful strategy in a purchasing environment?

This paper describes how within a study on the experiences of district nurses since the introduction of general practitioner purchasing, participants were encouraged to describe and define the district nursing service. The identification of terminal care by district nurses and others as a significant and defining example of district nursing work is explored and the possible reasons for its emphasis over other aspects of patient care. The extent to which terminal care was used within contract and purchasing discussions to aid general practitioner understanding of district nursing work and achieve extra funding is described. The paper concludes by questioning the extent to which terminal care is a helpful and accurate representation of what district nursing work entails, and the implications there may be in emphasizing one aspect of care within a purchasing environment.     

The future of palliative care nursing research in Australia

Nursing research in palliative care is becoming more important as cost effectiveness and evidence-based practice are becoming mandatory. Fifty-nine published and unpublished projects relating to nursing research on palliative care in Australia between 1990 and 1996 were reviewed. Findings indicated that nurses working in palliative care in Australia are interested in researching a range of topics using varied methods. The nurses' primary interests appear to be their own professional issues and management of the patient's pain. Little research on families/carers of palliative care patients was evident. There is a need for future research to focus on projects that justify the nurse's role in the palliative care team, show that nursing interventions for symptom control affect patient outcomes and prove nurses are integral to the psychosocial and spiritual wellbeing of the patient and family during the palliative care journey.     

The use of neonatal palliative care: Reducing moral distress in NICU nurses

The ethical dilemmas faced by nursing professionals can lead to moral distress and the abandonment of nursing as a career. This is especially true in intensive care nursing where mortality is more prevalent. Neonatal nurses face a particularly high rate of moral distress when dealing with the treatment and loss of critical infants. This distress is compounded when nurses feel that the care they are providing is not in the best interest of the infant. Providing palliative care at the end-of-life may alleviate some of this distress, but only if palliative care is implemented consistently and effectively. Several barriers exist to implementing effective palliative care. The primary barrier is the lack of education of neonatal staff in the correct definition and application of end-of-life comfort care. This includes education in communication, assessment of needs, and implementation. A neonatal-specific palliative care team (or individual palliative care nurse) can fill this gap in education to accommodate effective care. A consistent, effective neonatal palliative care program is essential. Such a program affords the opportunity for compassionate communication with the family, a decrease in moral distress for nurses, and the provision of quality end-of-life care for the neonate.     

The wider implications of an audit of care plan documentation

This article describes how the results of an audit of district nursing care plan documentation have been used to inform practice development in a community trust. The principle aim of the audit was to discover whether the evaluation of patient care was being adequately recorded in nursing care plans. To establish this, four commonly occurring areas of district nursing work were selected and an ideal assessment of care developed from the available evidence. The areas were: the management of leg ulceration, bath care, pressure area care and catheter care. Data capture forms were developed to record whether the features of an ideal assessment of these four areas of care were reflected in the written evaluation of that care. The results of the audit demonstrated that the evaluation of care was often inadequately recorded, which reflected poor written documentation of the initial nursing assessment. The implications of the findings of the audit for practice development in the four areas of care are discussed.     

Trappings of technology: casting palliative care nursing as legal relations

LARSEN A‐C. Nursing Inquiry 2012; 19 : 334–344
Trappings of technology: casting palliative care nursing as legal relations Community palliative care nurses in Perth have joined the throng of healthcare workers relying on personal digital assistants (PDAs) to store, access and send client information in ‘real time’. This paper is guided by Heidegger’s approach to technologies and Habermas’ insights into the role of law in administering social welfare programs to reveal how new ethical and legal understandings regarding patient information add to nursing’s professional responsibilities. This qualitative research interprets data from interviews with twenty community palliative care nurses about clients’ legal rights to informational privacy and confidentiality. It explores nurses’ views of their nursing responsibilities regarding clients’ legal rights, liability issues, bureaucratic monitoring and enforcement procedures. It concludes that nurses and clients are construed as legal subjects entrenched in legal relations that have magnified since these nurses began using PDAs in 2005/2006.     

社区家庭输液存在护理问题分析及对策

笔者介绍该院社区门诊开展家庭输液存在的护理问题及对策。主要护理问题有:安全系数比医院小,风险大;输液过程出现不良反应不能及时发现及时处理;家庭条件差,无法统一规范工作流程;病人及家属缺乏医学知识;社区护士压力大。采取对策:强化护士的法律意识;加强质量控制工作;重视社区护士的培训,提高护士素质;健康教育细致准确;人性化服务送入家庭。认为不断改进存在问题才能保证病人的医疗需求及安全防范。     

Nurses and palliation in the community: the current discourse

A core component of community nursing practice in Australia is the provision of palliative care, however this area of practice has been minimally researched. We, therefore, undertook a broader review of the contemporary literature in community nursing; palliative nursing; and community nursing palliative care. Literature was searched electronically in OVID, CINAHL and nursing databases and manually in relevant journals. Findings revealed community and palliative care nursing to be both complex and challenging. Community and palliative nurses ideals for care are compromised by competing practice demands. Changing health systems and philosophical views, limited resources and the perceived 'visibility/invisibility' polarity are identified as major job stressors. Therapeutic use of 'self' and interpersonal communication are recognized as contributing to job satisfaction. Community nurses providing palliative care is as an under researched area yet it is a role that arguably requires critical understanding and recognition. Further research is needed into the relationship between emotional well-being and professional satisfaction for community and palliative care nurses providing palliation.     

Developing palliative care practice in nursing and residential care homes: the role of the clinical nurse specialist

The development of practice is but one aspect of Clinical Nurse Specialists' (CNSs) work, and a number of factors act to shape the extent to which CNSs are able to work with and develop practice with nursing and residential care homes. A postal survey of 730 community CNSs in palliative care working in the UK was undertaken to explore the involvement of these nurses with nursing and residential care homes. Much of the focus of the involvement was reactive work meeting the direct clinical needs of residents, primarily with cancer. Although the CNSs perceived that there were some educational and care deficits in these care settings, the amount of proactive work undertaken to improve practice was limited. The development work undertaken was focused on educational initiatives and establishing link nurse systems. There is potential to develop palliative care practice in nursing and residential care homes through practice development initiatives.     

The experiences of Chinese family members of terminally ill patients - a qualitative study

Aim. To describe and understand the experiences of Chinese family members of terminally ill patients during the end of life process in a palliative care unit. Background. Palliative care aims to provide care to dying patients and their family members. Skillful interventions are necessary to help family members cope with the impending death of the patient and maintain their emotional equilibrium. Hence, it is important to understand the experiences of family members of palliative care. Design. A phenomenological study was conducted. Data were collected by semi‐structured interviews. We interviewed a purposive sample of 20 family members of terminally ill patients in a palliative care unit in Hong Kong. The data were analysed following Colaizzi's phenomenological methodology. Results. Family members experienced anticipatory grief, with reactions that included anger, unease, sadness and helplessness. This was particularly acute when the patient was first admitted to the palliative care unit. However, the family members quickly accepted the reality and committed themselves to the care of the patient, seeking informational and emotional support from the nurses. The families wanted to be assured that the patient had been offered good care and suffered no pain. It was considered important to be with the patient during the dying process. Conclusion. This study demonstrated that Chinese family members were committed to the care of the patients in the palliative care unit. Cultural beliefs played a part in influencing family emotions and concerns. Relevance to clinical practice. This study offers a direction for family interventions that acknowledge the reactions of family members to the admission of a patient to a palliative care unit. It highlights that families need active informational and emotional support from nurses.     

Complementary therapies as a means of developing the scope of professional nursing practice

The development of the extended role in nursing has been seen by some as primarily a means for nurses taking on tasks that have traditionally been the work of junior doctors. Others object to this view and ascribe to the 'new nursing' perspective of Salvage. She sees the extended role as moving towards increasing autonomy and operating in a professional rather than a bureaucratic occupational model. This view militates against the development of nurses as mini-doctors. This paper discusses the controversy surrounding the development of the extended role, focusing particularly on the use of complementary therapies as a legitimate component of the 'new nurses' role.     

A ward without walls? District nurses’ perceptions of their workload management priorities and job satisfaction

Aim. To explore district nurses’ workload management, job satisfaction and the challenges they face. Background. This paper reports qualitative findings from a qualitative and quantitative study to identify a district nursing perspective on use of time, challenges and work satisfaction. District nursing is under increasing pressure because of the increasing shift to care in the community, early hospital discharge and changes in demography with an ageing population and more people with chronic illnesses. Design. Qualitive. Method. The study took place in one Scottish Health Board and data were collected in February and March 2005. The qualitative approach involved a total of 31 district nurses and senior managers in focus group discussions or individual interviews. Results. Three main themes were identified: (1) the priorities of district nurses and their views on work unrelated to ‘hands on’ clinical care, (2) aspects of district nursing considered stressful and (3) district nurses’ job satisfaction. Conclusion. District nurses and managers agree that caring work with patients is the priority for the service and provides job satisfaction. Many nurses feel overwhelmed by their workload and have little control over the admission of patients to their caseload; they are mainly demand led and therefore reactive care providers. A culture of long hours has developed as district nurses struggle to meet the needs of patients. Feeling devalued lowers satisfaction and Agenda for Change is perceived as de‐valuing the skills of community nurses. Relevance to clinical practice. More clerical support is required so district nurses can deliver care to patients. District nurses can better represent their workload and how it is managed through expressing the nature of assessing risk and caring for patients as opposed to defining patients care needs by medical diagnoses. Extending the hours of the full district nursing service would benefit patients and staff.     

Improving district nurses' confidence and knowledge in the principles and practice of palliative care

Title.  Improving district nurses' confidence and knowledge in the principles and practice of palliative care.
Aim.  This paper is a report of part of an evaluation of the impact of a national palliative care education and support programme on the knowledge and confidence of members of district nursing teams.
Background.  District nursing teams are the mainstay of 'hands on' provision of care at home. In recognition of their central role, the English Department of Health commissioned a national palliative care education programme as postregistration education had been limited.
Methods.  The evaluation, conducted between 2002 and 2004, had a mixed methods design. In the summative component, 1280 nurses were randomly selected from eight cancer networks to receive postal questionnaires 1 year apart, before and after the educational intervention. Changes in scores were calculated and a multiple regression analysis undertaken to identify predictors of improvement in confidence in competence and knowledge. The formative component involved qualitative interviews with a sub-sample of 39 district nurses participating in the programme.
Findings.  Nurses who responded in both years (374/32%) were included in the analysis. There was a small statistically significant increase in confidence in palliative care competency and knowledge after participation in the educational programmes. Nurses without district nursing qualifications and who had never worked in specialist palliative care had the largest improvements in scores. Qualitative data supported these findings.
Conclusion.  The findings suggest that the education programme led to improvements in self-reported district nursing confidence in palliative care competencies and knowledge; it is likely that the baseline level of palliative care confidence in competency and knowledge has as a result been raised nationally.     

District nurses' experiences and perceptions of cancer patient referrals

Traditionally palliative care of cancer patients has been seen as an important and defining aspect of district nursing. Care of the dying patient has been used to describe the ability and scope of the district nursing service to holistically provide for patient need. However health and social service changes in the last decade have refocused the district nurse's role away from holistic delivery to more specialized care. There is also research evidence that there are several contradictions in referral processes to the district nursing service. We conducted a study to explore district nurses' perceptions and experiences of referral of cancer patients to gain insight into these referral processes. We interviewed 20 nurses from three primary care trusts to explore the referral process of cancer patients to the district nursing service from the district nurses' point of view. The nurses expressed concerns regarding completeness, accuracy and appropriateness of referral and suggested improvements that could be made.     

The conflict between 'new nursing' and 'scientific management' as perceived by surgical nurses

Nursing on surgical wards is a major area of employment for nurses, but the literature is sparse in relation to this group. Dramatic alterations in surgical care have occurred over the past few years, including the introduction of day surgery on a major scale, increased technical equipment and faster 'throughput' of patients. This has led to Nicholas Fox describing 'a conveyor belt of surgery'. These changes are occurring alongside major evolution within the nursing profession. Nurses are encouraged to give holistic, individualized care in what has been termed the 'new nursing' movement. This study addresses the problem of how nurses resolve these two conflicting discourses. Following an initial phase of participant observation, 10 registered surgical nurses were interviewed using the techniques of career biography, critical incident analysis and informal interviews. Different interpretations by the key members of the 'new nursing', discourse have been identified. These have been termed the professional project discourse, the modernist discourse, and the traditionalist discourse. Various strategies are adopted by nurses to reduce cognitive dissonance caused by the two conflicting discourses. The most commonly used being rationalization about the need for emotional labour.