A sense of security for cancer patients at home: the role of community nurses

The State of the Evidence about the Family and Community Nurse: A Systematic Review

Introduction. The increase in chronic degenerative diseases poses many challenges to the efficacy and sustainability of healthcare systems, establishing the family and community nurse (FCN) who delivers primary care as a strategic role. FCNs, indeed, can embrace the complexity of the current healthcare demand, sustain the ageing of the population, and focus on illness prevention and health promotion, ensuring a continuous and coordinated integration between hospitals and primary care ser. The literature on FCNs is rich but diverse. This study aimed to critically summarise the literature about the FCN, providing an overall view of the recent evidence. Methods. A state-of-art systematic review was performed on PubMed, CINAHL, and Scopus, employing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and checklist to guide the search and reporting. Results. Five interpretative themes emerged from the 90 included articles: clinical practice, core competencies, outcomes, Organisational and educational models, and advanced training program. Conclusions. FCNs can make a major contribution to a population’s health, playing a key role in understanding and responding to patients’ needs. Even if the investment in prevention does not guarantee immediate required strategies and foresight on the part of decisionmakers, it is imperative to invest more political, institutional, and economic resources to support and ensure the FCNs’ competencies and their professional autonomy.

Healthcare utilization of breast cancer patients following telephone-based consultations of oncology nurse navigator via telemedical care

Objectives

To characterize breast cancer patients who received telephone-based consultations of oncology nurse navigator via telemedical care (TMC patients) and analyze their healthcare utilization (HCU) one year before and after receiving this service.

Methods

A retrospective study among Maccabi Healthcare Services enrollees that were newly diagnosed during 2016 (n = 1035). HCU, demographic characteristics and comorbidities were obtained from computerized database. Multivariable ordered logit model was specified for the determinants of HCU by quarters. Independent variables included: annual number of telephone-based consultations, gap between diagnosis and first consultation, age, socio-economic status, eligibility for disability and income security benefits, and comorbidities.

Results

Twenty-two percent of our cohort were TMC patients. Compared to others, these patients were younger and had a lower prevalence of hypertension. A higher proportion of these patients received disability benefits, and a lower proportion received income security benefits. The total average annual HCU of TMC patients (n = 107) before first consultation was $8857 and increased to $44130 in the first year following it (p<0.001), predominantly due to a significant increase in outpatient visits ($20380 vs. $3502, p<0.001) and medication costs ($19339 vs. $1758, p<0.001). The multivariable model revealed that each additional telephone-based consultation decreased the likelihood to be in the lowest quarter of the HCU distribution by 1.1 percentage points (p = 0.015), and increased the likelihood to be in the upper quarter of the HCU distribution by 1.1 percentage points (p = 0.016).

Conclusions

There was a significant increase in outpatient care and medications usage following first consultation. Moreover, a more intense use of this service was associated with elevated HCU. This result may stem from the proactive nature of the telemedical care.

Visiting Nurses' Perspectives on Practices to Achieve End-of-Life Cancer Patients' Wishes for Death at Home: A Qualitative Study

Objective:

This study aimed to clarify visiting nurses’ perspectives on critical practices to ensure they could advocate for patients who prefer to die at home.

Methods:

Sixteen nurses, working at home-visit nursing agencies in Japan, participated in this study. Data were generated by interviews with the nurses and participant observations from nursing home-visits for six end-of-life cancer patients and were analyzed using content analysis.

Results:

Five themes emerged: (1) nursing assessment, (2) support for comfortable daily life of the patient and their family, (3) advocating for the patient's views about continuing homecare until death, (4) supporting the patient's preparedness for death, and (5) coordination with other health professionals and related facilities for a comfortable environment for the patient. In addition, the nurses sometimes used humorous responses to death-related work to change the patient's melancholy thoughts.

Conclusion:

The present study found that the participants advocated for the patient's views about continuing homecare until death while coordinating views between the patient and their family; they further supported the patient's daily life while helping them prepare for death to achieve their wish for death at home. In addition, our study uncovered the visiting nurses’ unconscious practical wisdom of using humorous responses to death-related work to alleviate the patients’ feelings of hopelessness. To develop practical wisdom for using humor effectively in end-of-life care, nurses need to verbalize unconscious practices, and accumulate empirical knowledge about nursing interventions using humor, including cultural attitudes, through case study analysis.

The theory of a co-creative process in advanced palliative home care nursing encounters: A qualitative deductive approach over time

AIMS AND OBJECTIVES

The aim of this study was to test the theoretical conceptualization of the co-creative process in home care nursing encounters over time.

METHOD AND DESIGN

This was a multiple case study with a deductive analysis of qualitative data over time, using interviews and observations collected from three cases.

RESULTS

The co-creative process was complex and contained main, sub- and micro-processes. Time was important and valuable, giving the patient and relatives space to adjust the process to their own pace. Some processes were worked on more intensively in accordance with the patients' and relatives' needs, and these are considered the main-process. The further developed theory of the co-creative process and its main, sub- and microprocesses can be understood as a concretization of how good nursing care can be performed within caring relationships in the context of advanced palliative home care.

Characteristics and outcome of unplanned hospital admissions in patients with lung cancer: a longitudinal tertiary center study. Towards a strategy to reduce the burden

BACKGROUND

Unplanned hospital admissions (UHAs) are frequent in lung cancer, but literature on this topic is scarce. The aim of this study is to gain insight in the demographics, patterns of referral, causes, presenting symptoms, and final outcome of these UHAs. A strategy to improve quality of care and reduce the number and cost of UHAs was suggested based upon these findings.

PATIENTS AND METHODS

In retrospective analysis of all consecutive UHAs in a 6-month period in a tertiary center, demographics, pattern of referral, clinical data, tumor control status, final diagnosis, duration of hospitalization, and outcome were examined.

RESULTS

Two hundred seven UHAs were recorded. Male/female ratio was 185/62, mean age 65.5 years, performance status (PS) on admission 0-1 in 32 %, 2 in 37.2 %, and 3-4 in 30.8 % of patients. Patient referral occurred by general practitioner in 33.6 % or specialist in 25.5 % and in 40.9 % on own initiative. UHAs were therapy-related in 23.9 %, cancer-related in 47.4 %, comorbidity-related in 19.4 %, or of unclear nature in 9.3 %. Most frequent causes were infections (21.9 %) and respiratory problems (17.0 %). Mean length of stay was 9.5 days. Final outcome was 10.1 % mortality, 6.9 % hospice care transfers, and 79.4 % home returns (including 18.2 % same day returns).

CONCLUSION

UHAs in lung cancer were more cancer- than therapy-related. Majority of patients (2/3) were not seen by their general practitioner. A significant number of same day returns were noted. UHAs in patients with poor PS, uncontrolled cancer and cancer-related events had the worst outcome. This work is a first step in identifying specific characteristics of UHAs in lung cancer patients, which may lead to strategies to reduce the burden of UHAs.

The effects of community-wide dissemination of information on perceptions of palliative care, knowledge about opioids, and sense of security among cancer patients, their families, and the general public

PURPOSE

Prejudices against palliative care are a potential barrier to quality end-of-life care. There have been few large-scale community-wide interventions to distribute appropriate information about palliative care, and no studies have investigated their impact on cancer patients, their families, and the general public. Thus, we conducted a 3-year community intervention and evaluated the effects of distributing such information at the community level, and explored associations among levels of exposure, perceptions, knowledge, and the sense of security achieved.

METHODS

Over a period of 3 years, we provided flyers, booklets, posters, and public lectures about palliative care in four regions of Japan, and carried out pre- and post-intervention surveys with repeated cross-sectional samplings of cancer patients (pre 859, post 857), bereaved family members (1110, 1137), and the general public (3984, 1435). The levels of exposure to the provided information were measured by a multiple-choice questionnaire after intervention. Multiple logistic regression analyses were used to estimate multivariable-adjusted odds ratios (ORs) for perceptions of palliative care, knowledge about opioids, and sense of security among the exposure groups.

RESULTS

Overall perceptions of palliative care, opioids, and receiving care at home improved significantly among the general public and families, but not among the patients at the community level. However, multiple regression revealed that patients of extensive exposure category had significantly more positive perceptions of palliative care to those of non-exposure category (p = 0.02). The sense of security regarding cancer care of all patients, family members, and the general public improved. Among others, the respondents who reported extensive exposure in the general public and family members scored significantly higher sense of security.

CONCLUSION

Our findings indicate that providing palliative care information via small media and lectures in the community is effective in improving perceptions of palliative care and knowledge about opioids among the community dwellers, especially for caregivers of the patients. The acquisition of adequate knowledge about palliative care from various information sources may improve people's sense of security regarding cancer.

The role of practice nurses in providing palliative and end-of-life care to older patients with long-term conditions

BACKGROUND

Many people with palliative care needs will receive care from a primary care provider. However, GPs often have limited time to deal with these patients' supportive care needs, which is where primary care nurses can make a significant contribution.

AIM

The aim of this qualitative descriptive study was to explore the role of practice nurses in the provision of palliative and end-of-life (EoL) care to older patients with long-term conditions.

METHODS

Twenty one practice nurses from a selection of rural and urban areas in New Zealand were interviewed about their EoL care experiences.

RESULTS

Three themes were identified relating to EoL care: variability of practice nurse involvement in EoL care, limited education and training in EoL care, and what practice nurses can (and do) contribute to EoL care.

CONCLUSION

Priority should be given to developing the palliative care skills and knowledge of primary care nurses and their ability to provide the necessary support to the growing number of patients who will require palliative care.

District nurse advocacy for choice to live and die at home in rural Australia: a scoping study

BACKGROUND

Choice to live and die at home is supported by palliative care policy; however, health resources and access disparity impact on this choice in rural Australia. Rural end-of-life home care is provided by district nurses, but little is known about their role in advocacy for choice in care.

OBJECTIVES

The study was conducted to review the scope of the empirical literature available to answer the research question: What circumstances influence district nurse advocacy for rural client choice to live and die at home?, and identify gaps in the knowledge.

METHOD

Interpretive scoping methodology was used to search online databases, identify suitable studies and select, chart, analyse and describe the findings.

RESULTS

34 international studies revealed themes of 'the nursing relationship', 'environment', 'communication', 'support' and 'the holistic client centred district nursing role.

DISCUSSION

Under-resourcing, medicalisation and emotional relational burden could affect advocacy in rural areas.

CONCLUSION

It is not known how district nurses overcome these circumstances to advocate for choice in end-of-life care. Research designed to increase understanding of how rural district nurses advocate successfully for client goals will enable improvements to be made in the quality of end-of-life care offered.

Encounters in home-based nursing care - registered nurses' experiences

The encounter between registered nurses and persons in need of healthcare has been described as fundamental in nursing care. This encounter can take place face-to-face in physical meetings and through meetings via distance-spanning technology. A strong view expressed in the literature is that the face-to-face encounter is important and cannot entirely be replaced by remote encounters. The encounter has been studied in various healthcare contexts but there is a lack of studies with specific focus on the encounter in home-based nursing care. The aim of this study was to explore the encounter in home-based nursing care based on registered nurses' experiences. Individual interviews were performed with 24 nurses working in home-based nursing care. The transcribed interviews were analyzed using thematic content analysis and six themes were identified: Follows special rules, Needs some doing, Provides unique information and understanding, Facilitates by being known, Brings energy and relieves anxiety, and Can reach a spirit of community. The encounter includes dimensions of being private, being personal and being professional. A good encounter contains dimensions of being personal and being professional and that there is a good balance between these. This is an encounter between two human beings, where the nurse faces the person with herself and the profession steadily and securely in the back. Being personal and professional at the same time could encourage nurses to focus on doing and being during the encounter in home-based nursing care.

Early support visits by district nurses to cancer patients at home: a multi-perspective qualitative study

BACKGROUND

Many palliative cancer patients spend much of their last year at home. In the UK, district nurses make frequent support visits to patients and carers at this time, yet surprisingly little is known about their supportive role in palliative care. Current studies are limited to district nurses' reports of practice, which offer limited insight into their content. Patients' and carers' views on district nurse support visits are largely unknown.

AIM

To present findings of a multi-perspective study that explored how district nurse early support visits are both described and carried out.

DESIGN

Focus groups with district nurses to explore views on the purpose of early support visits. Observation of support visits to identify how they are conducted. Patient and carer interviews to elucidate and verify district nurse data.

SETTING AND PARTICIPANTS

Participants included 58 district nurses, 10 palliative care patients and nine carers from four Primary Care Trusts in contrasting urban and rural locations.

RESULTS

District nurses had difficulty articulating early support visits. Observations however revealed a complex role comprising extensive physical and practical assessments, practical interventions, information giving, liaison, facilitation and referral. Patients and carers confirmed that they felt valued, reassured and supported by district nurses.

CONCLUSIONS

A multi-perspective approach provided new insights into district nurse support visits. Monitoring work described appears to have additional psycho-social benefits for patients and carers. The supportive role of district nurses needs to be clearly articulated and recognised so that colleagues, patients and carers access this valuable resource for palliative care patients.

‘Catching up’: The significance of occupational communities for the delivery of high quality home care by community nurses

This article examines the importance of some informal work practices among community nurses during a period of significant organizational change. Ethnographic fieldwork in two purposively selected adult community nursing services in England comprised 79 hours of observation of routine practice, 21 interviews with staff and 23 interviews with patients. We identified the informal work practice of ‘catching up’, informal work conversations between immediate colleagues, as an important but often invisible aspect of satisfying work relationships and of the relational care of patients. Drawing on anthropological literatures on ‘communities of practice’ the article examines two central issues concerning the practices of ‘catching up’: (1) how informal learning processes shape community nursing work; (2) how this informal learning is shaped both in relation to the ideals of community nursing work and the wider political and organizational contexts of community nursing practice. Our findings highlight the distinctive value of informal workplace ‘catch ups’ for nurses to manage the inherent challenges of good home care for patients and to develop a shared ethic of care and professional identity. Our findings also indicate the decline of ‘catching up’ between nurses along with diminishing time and opportunity for staff to care holistically for patients in present service climates.

A qualitative exploration of the role of primary care in supporting colorectal cancer patients

PURPOSE

To explore experiences and support needs of people with colorectal cancer, with a focus on identifying opportunities for primary care interventions.

METHODS

We conducted a new qualitative analysis of an existing dataset, comprising semi-structured interview transcripts from 39 people with colorectal cancer from across the UK, interviewed in 2001-2002 for www.healthtalkonline.org . Then, we conducted semi-structured interviews with 30 people with colorectal cancer from North East Scotland and Glasgow in 2009 and analysed these new data to explore themes and challenge hypotheses that emerged from the Healthtalkonline data.

RESULTS

Formal sources of support, including that from primary care, were valued by those who received them, but provision was described as sporadic both in 2002 and in 2009. However, more of the 2009 participants gave descriptions of specialist nurse and community nurse involvement, and telephone contact from general practitioners, which were welcomed. Improvements in meeting information needs, particularly on the issues of diet and sex, were identified by 2009. A recurring issue reported by patients was the distress experienced by their own friends and family; some patients found themselves having to provide, rather than receive, emotional support at this difficult time.

CONCLUSIONS

There have been improvements in support for people with colorectal cancer since 2002, with more specialist and community nurse involvement, and telephone contact from general practitioners, but provision remains piecemeal. Patients would benefit if their families received support, and primary care may be in a good position to provide this. A proactive approach from general practitioners in the post-discharge period is valued.

Nurses' needs in delivering palliative care for long-term conditions

This study addressed the question 'What are the needs of community nurses in delivering palliative care to people with long-term conditions?' A qualitative exploratory descriptive design was employed. Ten community nurses (Band 5-7) were recruited from a purposive sample following a process of randomised stratified sampling, according to geographical area and Band for matched numbers. Semi-structured interviews were undertaken and audio recorded with written informed consent. The interviews were transcribed verbatim and analysed using an adapted Burnard's framework. The study found that establishing therapeutic relationships, having access to resources, co-ordination and provision of clinical care and collaborative working were all highlighted by the community nurses as needs in delivering palliative care. If these four needs were met, the community nurses believed they could deliver palliative care to their patients. Issues around a lack of resources, community nurses' educational needs and the late referral of patients with non-malignant long-term conditions to community nursing were also identified.

Predictors of home death of home palliative cancer care patients: a cross-sectional nationwide survey

OBJECTIVES

To identify factors influencing the place of death among home palliative cancer care patients, focusing on the role of nurses in terms of pre- and post-discharge from hospital to home care settings.

DESIGN, SETTINGS AND PARTICIPANTS

A cross-sectional nationwide questionnaire survey was conducted at 1000 randomly selected homecare agencies in Japan. The questionnaires were completed by primary community nurses of home palliative patients just after their discharge. A total of 568 responses were analyzed (effective response rate, 69%).

RESULTS

Multivariate logistic regression analysis revealed the following independent factors of place of death among those patients: desire for home death at referral by both patient and family caregiver; caregiver relationship to patient as daughter or daughter-in-law; totally bedridden functional status of patient; patient not suffering from depression and/or anxiety at referral; patients and caregivers duly informed about the dying process/death in detail, as well as instructed by community nurses about pain management and how to treat/prevent bedsores in home care settings.

CONCLUSIONS

This study demonstrated the importance of both the hospital and community nurses' role in increasing the patients' chance of dying at home. Hospital nurses should support early transfer to home palliative care according to their assessment of the desire of patient/family caregiver for home death, the patients' clinical status, and caregivers' ability to provide patient care at home. Community nurses should inform patients/family caregiver in detail about the dying process/death just after discharge, relieve patient pain, treat/prevent bedsores, and instruct family caregivers on their symptom control.

Barriers to dying at home: the impact of poor co-ordination of community service provision for patients with cancer

For patients dying of cancer, there is an emphasis on giving choice regarding preferred location for care, with the option of dying at home, which is integral to UK government health initiatives such as the End of Life Care Programme. However, patients continue to be admitted to hospital in the terminal phase of their illness when they have expressed a desire to die at home. A qualitative study, using two audio tape-recorded focus group interviews, with a purposive sample of district nurses and community specialist palliative care nurses (19) was undertaken across two primary care trusts in the north west of England. Data were analysed using a thematic analysis approach. From a service provision perspective, the results reveal that poor discharge planning and co-ordination, difficulty in establishing additional equipment and services together with inadequate out of hours medical provision were all factors contributing to hospital admissions for patients with cancer in the last hours and days of life, and thus were barriers to dying at home.

Chemotherapy outpatients' unplanned presentations to hospital: a retrospective study

GOAL OF WORK

This descriptive, retrospective study sought to identify the nature and magnitude of chemotherapy outpatients' unplanned presentations and admissions to the emergency department and/or cancer centre at a large metropolitan tertiary hospital, and to explore the antecedents to those presentations.

PATIENTS AND METHODS

Retrospective data were collected for outpatients who made an unplanned presentation to a large metropolitan hospital in Sydney, Australia between October 1, 2006 and September 30, 2007. Detailed information was collected for those who had received cytotoxic chemotherapy at the hospital's cancer centre within the 6 months prior to the unplanned presentation to hospital. Demographic and explanatory variables were identified, including: reasons for presentation, cancer diagnosis, chemotherapy regimens, and position in the chemotherapy trajectory.

MAIN RESULTS

The Cancer Institute NSW figures indicate that each year approximately 518 outpatients are treated with chemotherapy at the participating cancer centre. During the study period, 316 cancer outpatients made 469 unplanned presentations to either the Cancer Centre or the hospital emergency department. Of those outpatients presented, 233 (73.7%) had received chemotherapy in the previous 6 months and made a total of 363 presentations. Of these 363 presentations, 253 (69.7%) occurred within 4 weeks of receiving chemotherapy. The majority of presentations by those who had received chemotherapy in the previous 6 months resulted in hospital admission (87.6%) for a median length of stay of 5 days. The most frequent presentation symptoms were nausea and/or vomiting (45.2%), pain (27%), fever and/or febrile neutropenia (23.4%), shortness of breath (19.3%), dehydration (12.1%), anaemia (8.8%), fatigue (8.8%), diarrhoea (8.8%), and anxiety and/or depression (5.5%).

CONCLUSIONS

Chemotherapy outpatients have significant unmet needs following treatment, indicating an urgent need for improved continuity of care and better integration of primary and tertiary health care services.

Community palliative care: role perception

Community nurses play a key part in palliative care for patients and their families, yet there is relatively little research examining how their role is understood by nurses themselves. This paper presents findings from a qualitative study exploring how district nursing teams and community matrons (CMs) understood their own and each other's roles in palliative care. Twenty-four district nurses (DNs), 15 CMs and seven other key stakeholders were interviewed. DNs saw themselves as having a pivotal role, often coordinating other services as well as providing hands-on care. CMs agreed with the importance of the DN role, but had doubts about whether DNs had the capacity or skills to provide genuine case management. Both sets of nurses varied in their views of the CM role in palliative care, from seeing it as negligible to extensive and valuable. Organizational change contributed to the defensiveness of many DNs about their role, and to CMs' experiences of suspicion towards theirs.