Rural nursing and quality end-of-life care: palliative care ... palliative approach ... or somewhere in-between?

Patient and family perspectives on rural palliative care models: A systematic review and meta-synthesis

BACKGROUND

Almost half the world's population lives in rural areas. How best to provide palliative care to rural populations is unclear. Privileging rural patient and family voices about their experiences of receiving care delivered via rural palliative care models is necessary.

AIM

To identify the key palliative care elements that rural patients with palliative care needs and their families perceive to be critical to receiving the care and support they need to live well.

DESIGN AND DATA SOURCES

A systematic review and meta-synthesis registered with Prospero (CRD42020154273). Three databases were searched in June 2024. Raw qualitative data were extracted and analysed using Thomas and Harden's three-stage thematic synthesis methodology. Findings reported according to the PRISMA statement.

RESULTS

Of the 10,834 identified papers, 11 met the inclusion criteria. Meta-synthesis of extracted, raw quotes (n = 209) revealed three major themes: (1) Honouring the patient's existing relationship with their General Practitioner (GP); (2) strategically timed access to specialist services, clinicians and equipment is critical; and (3) a need to feel safe, prepared and supported.

CONCLUSION

The strategic inclusion of specialists alongside primary care providers is integral to optimising rural palliative care models. General Practioners are central to these models, through being embedded in their communities and as the conduit to specialist palliative care services. Rural palliative care patients and families value responsive care, trajectory signposting, effective communication, 24/7 support and recognise the value of virtual health. Globally, positive public policy and funding is critical to ensuring access to GP-led, specialist-supported, rural palliative care models.

Dying at "home" - a qualitative study of end-of-life care in rural Northern Norway from the perspective of health care professionals

BACKGROUND

'Most patients want to die at home' is a familiar statement in palliative care. The rate of home deaths is therefore often used as a success criterion. However, providing palliative care and enabling patients to die at home in rural and remote areas may be challenging due to limited health care resources and geographical factors. In this study we explored health care professionals' experiences and reflections on providing palliative care to patients at the end of life in rural Northern Norway.

METHODS

This is a qualitative focus group and interview study in rural Northern Norway including 52 health care professionals. Five uni-professional focus group discussions were followed by five interprofessional focus group discussions and six individual interviews. Transcripts were analysed thematically.

RESULTS

Health care professionals did their utmost to fulfil patients' wishes to die at home. They described pros and cons of providing palliative care in rural communities, especially their dual roles as health care professionals and neighbours, friends or even relatives of patients. Continuity and carers' important contributions were underlined. When home death was considered difficult or impossible, nurses expressed a pragmatic attitude, and the concept of home was extended to include 'home place' in the form of local health care facilities.

CONCLUSIONS

Providing palliative care in patients' homes is professionally and ethically challenging, and health care professionals' dual roles in rural areas may lead to additional pressure. These factors need to be considered and addressed in discussions of the organization of care. Nurses' pragmatic attitude when transfer to a local health care facility was necessary underlines the importance of building on local knowledge and collaboration. Systematic use of advance care planning may be one way of facilitating discussions between patients, family carers and health care professionals with the aim of achieving mutual understanding of what is feasible in a rural context.

I didn't want to remember memories of caring, but I can't help it": A qualitative study of the experiences of bereaved Iranian carers with elevated levels of prolonged grief symptoms

The lived experience of caring for people with cancer and the influence of culture on Iranian carers who have elevated levels of prolonged grief symptoms after the death has received little in-depth attention. Bereaved carers (N = 17) were interviewed. All showed high levels of prolonged grief symptoms. Thematic analysis resulted in four overarching themes: unfamiliarity with cancer, high involvement in carer's role, lack of processing events, and emptiness. The way that carers of cancer patients understand and cope with their caring role and their dominant cultural context can make their grieving process complex.

Adapting and Going the Extra Mile: A Qualitative Study of Palliative Care in Rural Northern Norway From the Perspective of Healthcare Providers

BACKGROUND

Despite significant developments in palliative care in recent decades, we still find important differences in access to and delivery of care in rural Norway.

OBJECTIVE

The aim of this study was to explore what healthcare professionals consider necessary to provide equality in care for palliative patients in rural areas.

METHODS

A qualitative approach with focus group discussions and individual interviews with 52 health professionals was used, starting with 5 uniprofessional focus groups of general practitioners and nurses/cancer nurses, followed by 5 interprofessional groups and 6 individual interviews. Interview transcripts were analyzed thematically.

RESULTS

We found local variations in organization, competence and access to palliative care, and challenging geographical conditions. It was essential to be proactive, flexible and willing to go the extra mile, but this may conceal the need for a stronger focus on competence and organization of palliative care. Access to written guidelines and practical tools was important, as was forming palliative teams for particular situations.

CONCLUSIONS

Palliative care needs strengthening in rural areas, and increased competence for all healthcare professionals is vital to increase equality in care. Geographical conditions require locally adapted solutions. Access to guidelines and interprofessional collaboration are essential.

IMPLICATIONS FOR PRACTICE

Rural palliative care needs in Norway are improving, as exemplified by at least 1 cancer nurse assigned to each local authority, and access to guidelines and palliative tools and interprofessional collaboration.

Barriers to Staff Involvement in End-of-Life Decision-Making for Long-Term Care Residents with Dementia

ABSTRACTAlthough providing direct care to residents with dementia, long-term care (LTC) home staff of registered nurses', registered practical nurses', and personal support workers' involvement in end-of-life decision-making is rarely acknowledged. The purpose of this study was to examine barriers and facilitators to LTC home staff involvement in end-of-life decision-making for people with advanced dementia. We report on the barriers to staff involvement in decision-making. Using an interpretive descriptive design, four major barriers to staff involvement in decision-making were identified: (a) the predominance of a biomedical model of care; (b) a varied understanding of a palliative approach; (c) challenging relationships with families; and (d) a discomfort with discussing death. Findings suggest that the predominant biomedical model in LTC homes, while important, must be imbued with a philosophy that emphasizes relationships among residents with dementia, family and staff.

Discourses Reproducing Gender Inequities in Hospice Palliative Home Care

BACKGROUND

As home is a site where gendered attitudes, beliefs, and practices are reproduced, it is imperative that policies and practices promote gender equity in end-of-life care at home.

PURPOSE

The purpose of this study was to critically analyze gender relations in the sociopolitical context of hospice palliative home care.

METHODS

Using a critical feminist perspective, we examined gender relations between and among clients with cancer, their family caregivers, and nurses in hospice palliative home care. Ethnographic methods of in-depth interviews (n = 25), observations of home visits (n = 9), and review of documents (n = 12) were employed to expose gender (in)equities.

FINDINGS

This critical analysis sheds light on institutional discourses that reproduce gender inequities: discourses of difference and denial; discourses of individuality, autonomy, and choice; and discourses of efficiency, objectivity, and rationality. Although gender was discounted, these neoliberal discourses reinforced traditional gender relations.

DISCUSSION

Neoliberal discourses frame health and health-care experiences as resulting primarily from individual behaviors and biomedical factors, permitting health-care providers and policy makers to overlook power relations and the sociopolitical forces that obscure gender inequities. A critical perspective is needed to consider how social structures significantly shape everyday gendered experiences in hospice palliative home care.

End-of-Life Communication: Nurses Cocreating the Closing Composition With Patients and Families

Communication is imperative for end-of-life decision-making; however, descriptions of key strategies used by nurses are missing. A phenomenological approach was used to interpret interviews from 10 hospice/palliative nurses. The overarching pattern is the closing composition. Key communication strategies/patterns include establishing context, acknowledging through attentive listening, making it safe for them to die, planning goals of care, and being honest. Essential is the awareness that nurse, patient, and family all hold expertise in the subject matter. It is imperative that pre-/postnursing licensure curriculum be expanded to include training in mutual influence communication practices and mentoring in the skill of orchestration.

The development of a spatial palliative care index instrument for assessing population-level need for palliative care services

We developed an index to measure potential need for palliative care services (PCIX). This is an instrument that enables spatial identification of potential population-level need for palliative care services and can be developed using census data. Four indicators of potential need for palliative care services -age, sex, living arrangement, socio-economic status (SES)-were used to produce composite potential need scores for DAs. Scores were graphically mapped, producing a spatial delineation of relative need for end-of-life services. To assess the benefit of combining multiple variables to define potential need, PCIX resolution was compared to general SES-based delineations of need. PCIX scores and maps were generated for all DAs, revealing spatial variability in potential need for palliative care services (PCS). Comparison of PCIX maps to those based on purely on SES indicated that use of variables specifically linked to palliative need resulted in more precise delineations of potential populations in need of PCS. Using composite scores - based on freely available census data - to spatially assess potential need for palliative care services can provide critical data for decision makers charged with rationalizing service locations and service capacity.

Identification of drug combinations administered by continuous subcutaneous infusion that require analysis for compatibility and stability

Background

A continuous subcutaneous infusion (CSCI) delivered via syringe pump is a method of drug administration used to maintain symptom control when a patient is no longer able to tolerate oral medication. Several classes of drugs, such as opioids, antiemetics, anticholinergics, antipsychotics and benzodiazepines are routinely administered by CSCI alone or in combinations. Previous studies attempting to identify the most-common CSCI combinations are now several years old and no longer reflect current clinical practice. The aim of this work was to review current clinical practice and identify CSCI drug combinations requiring analysis for chemical compatibility and stability.

Methods

UK pharmacy professionals involved in the delivery of care to palliative patients in hospitals and hospices were invited to enter CSCI combinations comprised of two or more drugs onto an electronic database over a 12-month period. In addition, a separate Delphi study with a panel of 15 expert healthcare professionals was completed to identify a maximum of five combinations of drugs used to treat more complex, but less commonly encountered symptoms unlikely to be identified by the national survey.

Results

A total of 57 individuals representing 33 separate palliative care services entered 1,945 drug combinations suitable for analysis, with 278 discrete combinations identified. The top 40 drug combinations represented nearly two-thirds of combinations recorded. A total of 23 different drugs were administered in combination and the median number of drugs in a combination was three. The Delphi study identified five combinations for the relief of complex or refractory symptoms.

Conclusion

This study represents the first step towards developing authoritative national guidance on the administration of drugs by CSCI. Further work will ensure healthcare practitioners have the knowledge and confidence that a prescribed combination will be both safe and efficacious.

Palliative Care in Critical Rural Settings

The United States has 1332 critical access hospitals. These hospitals have fewer than 25 beds each and a mean daily census of 4.2 patients. Critical access hospitals are located in rural areas and provide acute inpatient services, ambulatory care, labor and delivery services, and general surgery. Some, but not all, critical access hospitals offer home care services; a few have palliative care programs. Because of the millions of patients living with serious and life-threatening conditions, the need for palliative care is increasing. As expert generalists, rural nurses are well positioned to provide care close to home for patients of all ages and the patients' families. A case report illustrates the role that nurses and critical access hospitals play in meeting the need for high-quality palliative care in rural settings. Working together, rural nurses and their urban nursing colleagues can provide palliative care across all health care settings.

Developing Navigation Competencies to Care for Older Rural Adults with Advanced Illness

Navigators help rural older adults with advanced illness and their families connect to needed resources, information, and people to improve their quality of life. This article describes the process used to engage experts - in rural aging, rural palliative care, and navigation - as well as rural community stakeholders to develop a conceptual definition of navigation and delineate navigation competencies for the care of this population. A discussion paper on the important considerations for navigation in this population was developed followed by a four-phased Delphi process with 30 expert panel members. Study results culminated in five general navigation competencies for health care providers caring for older rural persons and their families at end of life: provide patient/family screening; advocate for the patient/family; facilitate community connections; coordinate access to services and resources; and promote active engagement. Specific competencies were also developed. These competencies provide the foundation for research and curriculum development in navigation.

A Review of Mental Health Approaches for Rural Communities: Complexities and Opportunities in the Canadian Context

Three mental health approaches with potential relevance to rural Canada were reviewed: telepsychiatry, integrated mental health models, and community-based approaches. These approaches have been evaluated in relation to their cost-effectiveness, comprehensiveness, client-centredness, cultural appropriateness, acceptability, feasibility and fidelity; criteria that may vary amidst rural contexts. Collaborative approaches to care, technologies fully integrated into local health systems, multi-sectoral capacity-building, and further engagement with informal social support networks may be particularly promising strategies in rural communities. More research is required to determine rural mental health pathways among diverse social groups, and further, to establish the acceptability of novel approaches in mental health.

Educating registered nursing and healthcare assistant students in community-based supportive care of older adults: A mixed methods study

BACKGROUND

Collaborative education that prepares nursing and healthcare assistant students in supportive care for older adults living at home with advanced chronic illness is an important innovation to prepare the nursing workforce to meet the needs of this growing population.

OBJECTIVES

To explore whether a collaborative educational intervention could develop registered nursing and healthcare assistant students' capabilities in supportive care while enhancing care of clients with advanced chronic illness in the community.

DESIGN

Mixed method study design.

SETTING

A rural college in Canada.

PARTICIPANTS

Twenty-one registered nursing and 21 healthcare assistant students completed the collaborative workshop. Eight registered nursing students and 13 healthcare assistant students completed an innovative clinical experience with fifteen clients living with advanced chronic illness.

METHODS

Pre and post-test measures of self-perceived competence and knowledge in supportive care were collected at three time points. Semi-structured interviews were conducted to evaluate the innovative clinical placement.

RESULTS

Application of Friedman's test indicated statistically significant changes on all self-perceived competence scores for RN and HCA students with two exceptions: the ethical and legal as well as personal and professional issues domains for HCA students. Application of Friedman's test to self-perceived knowledge scores showed statistically significant changes in all but one domain (interprofessional collaboration and communication) for RN students and all but three domains for HCA students (spiritual needs, ethical and legal issues, and inter-professional collaboration and communication). Not all gains were sustained until T-3. The innovative community placement was evaluated positively by clients and students.

CONCLUSIONS

Collaborative education for nursing and healthcare assistant students can enhance self-perceived knowledge and competence in supportive care of adults with advanced chronic illness. An innovative clinical experience can maximize reciprocal learning while providing nursing services to a population that is not receiving home-based care.

Palliative care professional education via video conference builds confidence to deliver palliative care in rural and remote locations

BACKGROUND

People living in rural and remote locations are disadvantaged in accessing palliative care. This can be attributed to several factors including the role diversity and the low numbers of patients with specific conditions, as well as the difficulties rural health practitioners have in accessing opportunities for professional education. A program of multidisciplinary palliative care video conferences was presented to health practitioners across part of northern Australia in an effort to address this problem.

METHOD

The educational content of the video conferences was developed from participant responses to an educational needs assessment. Following cycles of four consecutive video conferences, 101 participants completed evaluative on-line surveys. The quantitative data were analysed using frequencies and analysis of variance tests with post-hoc analyses where appropriate, and an accessibility and remoteness index was used to classify their practice location.

RESULTS

All participants found the content useful regardless of their remoteness from the tertiary centre, their years of experience caring for palliative care patients or the number of patients cared for each year. However, change in confidence to provide palliative care as a result of attending the video conferences was significant across all disciplines, regardless of location. Doctors, medical students and allied health professionals indicated the greatest change in confidence.

CONCLUSIONS

The provision of professional education about palliative care issues via multidisciplinary video conferencing increased confidence among rural health practitioners, by meeting their identified need for topic and context specific education. This technology also enhanced the networking opportunities between practitioners, providing an avenue of ongoing professional support necessary for maintaining the health workforce in rural and remote areas. However, more attention should be directed to the diverse educational needs of allied health professionals.

Development of a practice tool for community-based nurses: the Heart Failure Palliative Approach to Care (HeFPAC)

BACKGROUND

Patients living with advanced heart failure (HF) require a palliative approach to reduce suffering. Nurses have described significant knowledge gaps about the disease-specific palliative care (PC) needs of these patients. An intervention is required to facilitate appropriate end-of-life care for HF patients.

AIMS

The purpose of this study was to develop a user-friendly, evidence-informed HF-specific practice tool for community-based nurses to facilitate care and communication regarding a palliative approach to HF care.

METHODS

Guided by the Knowledge to Action framework, we identified key HF-specific issues related to advanced HF care provision within the context of a palliative approach to care. Informed by current evidence and subsequent iterative consultation with community-based and specialist PC and HF nurses, a pocket guide tool for community-based nurses was created.

RESULTS

We developed the Heart Failure Palliative Approach to Care (HeFPAC) pocket guide to promote communication and a palliative approach to care for HF patients. The HeFPAC has potential to improve the quality of care and experiences for patients with advanced HF. It will be piloted in community-based practice and in a continuing education program for nurses.

CONCLUSION

The HeFPAC pocket guide offers PC nurses a concise, evidence-informed and practical point-of care tool to communicate with other clinicians and patients about key HF issues that are associated with improving disease-specific HF palliative care and the quality of life of patients and their families. Pilot testing will offer insight as to its utility and potential for modification for national and international use.