Should an Acute Palliative Care Unit be Mandatory for Cancer Centers and Tertiary Care Hospitals?

Acute palliative care units have been developing in the last years and their clinical activity and characteristics have been described, despite large differences in different countries. One controversial topic is whether such units should be mandatory as standard in comprehensive cancer centers or even in tertiary hospitals. In this "Controversies in Palliative Care" article, three expert clinicians independently answer this question. Specifically, each group provides a synopsis of the key studies that inform their thought processes, share practical advice on their clinical approach, and highlight the opportunities for future research. Interestingly, all three experts arrived at similar conclusions. They underscored the importance of an acute palliative care unit, which provides a different pattern of activities in comparison with typical inpatient hospices, generally caring for patients who have a limited expected survival.

Psychological well-being of hospice staff: systematic review

BACKGROUND

Poor psychological well-being among healthcare staff has implications for staff sickness and absence rates, and impacts on the quality, cost and safety of patient care. Although numerous studies have explored the well-being of hospice staff, study findings vary and the evidence has not yet been reviewed and synthesised. Using job demands-resources (JD-R) theory, this review aimed to investigate what factors are associated with the well-being of hospice staff.

METHODS

We searched MEDLINE, CINAHL and PsycINFO for peer-reviewed quantitative, qualitative or mixed-methods studies focused on understanding what contributes to the well-being of hospice staff who provide care to patients (adults and children). The date of the last search was 11 March 2022. Studies were published from 2000 onwards in the English language and conducted in Organisation for Economic Co-operation and Development countries. Study quality was assessed using the Mixed Methods Appraisal Tool. Data synthesis was conducted using a result-based convergent design, which involved an iterative, thematic approach of collating data into distinct factors and mapping these to the JD-R theory.

RESULTS

A total of 4016 unique records were screened by title and abstract, 115 full-text articles were retrieved and reviewed and 27 articles describing 23 studies were included in the review. The majority of the evidence came from studies of staff working with adult patients. Twenty-seven individual factors were identified in the included studies. There is a strong and moderate evidence that 21 of the 27 identified factors can influence hospice staff well-being. These 21 factors can be grouped into three categories: (1) those that are specific to the hospice environment and role, such as the complexity and diversity of the hospice role; (2) those that have been found to be associated with well-being in other similar settings, such as relationships with patients and their families; and (3) those that affect workers regardless of their role and work environment, that is, that are not unique to working in a healthcare role, such as workload and working relationships. There was strong evidence that neither staff demographic characteristics nor education level can influence well-being.

DISCUSSION

The factors identified in this review highlight the importance of assessing both positive and negative domains of experience to determine coping interventions. Hospice organisations should aim to offer a wide range of interventions to ensure their staff have access to something that works for them. These should involve continuing or commencing initiatives to protect the factors that make hospices good environments in which to work, as well as recognising that hospice staff are also subject to many of the same factors that affect psychological well-being in all work environments. Only two studies included in the review were set in children's hospices, suggesting that more research is needed in these settings.

PROSPERO REGISTRATION NUMBER

CRD42019136721 (Deviations from the protocol are noted in Table 8, Supplementary material).

Overcoming the monster! Perceptions of physiotherapy students regarding the use of stroke master plots for building therapeutic relationships; a vignette study

BACKGROUND

Narrative master plots identify illness stories which are recognisable within clinical settings. Responses to different master plots by physiotherapy students can lack empathy and need to be understood further. One narrative master plot for people with stroke that has not been well studied is called 'overcoming the monster'. Research is needed to understand physiotherapy students' reactions to this master plot.

OBJECTIVE

To examine the responses of physiotherapy students to three variations of the master plot called 'overcoming the monster' generated from patients who have had a stroke.

METHODS

A qualitative narrative vignette study was undertaken. A university in the West Midlands (England) was used to access physiotherapy students on the pre-registration programs. A purposive sample of students volunteered to complete a single vignette questionnaire at one time point. The vignette provided three unique examples of the master plot overcoming the monster as told by people with stroke. Students responded to each by asking specific questions that captured demographic information and questions that captured reactions to the different versions of the master plot. Categorical-content narrative analysis was undertaken.

RESULTS

Thirty-two first year (BSc) students, thirty-nine first year (pre-registration) MSc students and nineteen third year (BSc) students participated in this study. Neither first year groups had undertaken any clinical placement hours. All third-year students had finished the required clinical placement hours for the physiotherapy course. Students consistently demonstrated empathy towards this master plot. Students often valued the variant of the story which illustrated how difficulties following stroke could be experienced as an 'adventure'. Students also valued and were motivated by the story variant that considered a family member as a source of motivation and encouragement. The story variant which focused on the shortcomings of the health care system was more often related to by the final year BSc students and MSc students. However, first year students, particularly BSc students, reported being more emotionally affected by the vignette.

CONCLUSION

All variants of the master plot overcoming the monster appeared to generate empathetic responses. This is important because it highlights the value of students' understanding the patients' story and challenges or 'monsters' faced. Therapeutic relationships will benefit from training physiotherapy students on the importance of listening and exploring challenges people with stroke face.

Investigating job satisfaction in palliative rehabilitation: Reflections and perspectives of health professionals working with amyotrophic lateral sclerosis

STUDY RATIONALE

Amyotrophic lateral sclerosis is a progressive neurodegenerative disease which causes impairment of the motor functions in the upper and lower limbs and bulbar muscles with a median survival time is three years from the first appearance of symptoms. There is massive psychological impact on health professionals to persons with amyotrophic lateral sclerosis, hence the work leads to multiple challenges and stressful and demanding situations with high risk of experiencing diminished personal well-being including burnout, moral distress, and compassion fatigue.

AIM

To investigate reflections and perspectives from health professionals working within palliative rehabilitation for elements of importance in relation to job satisfaction.

METHODS AND MATERIALS

The design was qualitative and based on the phenomenological-hermeneutical methodology by Paul Ricoeur's interpretation theory. Data consisted of two semi-structured focus group interviews with a total of 12 specialized health professionals: Nurses, Psychologists, Physicians, Occupational Therapists, Physiotherapists, and Social workers, working within a hospital setting of specialized palliative rehabilitation for people with amyotrophic lateral sclerosis and their families.

RESULTS

The analysis revealed insight into four themes: fundamental drive, working conditions, value of collegiality and work-life balance. Fundamental drive was deeply rooted in the professionals' sense of having a meaningful job. Working conditions such as self-management were important for job satisfaction as were good collegial relations. Finally, a good balance between working life and private life was considered important for job satisfaction.

CONCLUSION

Our study indicates that work within the field of palliative rehabilitation is experienced as enriching and beneficial under the right circumstances and in an appreciatory working environment. We found elements like autonomy, mastery, purpose, collegiality, and work-life balance to be of great importance. Our findings can help guide managements and health professionals in other palliative rehabilitation contexts to ensure satisfied employees and to optimize the quality of care.

Hospice Care: Hope and Meaning in Life Mediate Subjective Well-Being of Staff

OBJECTIVES

Subjective well-being has been associated with decreased work burnout and elevated work engagement. We investigated the impact of hope and meaning in life on subjective well-being among workers in a hospice care setting. Comparison was made to health-care workers in a rehabilitation unit.

METHODS

Thirty-five hospice care workers were surveyed and their responses compared with those of 36 rehabilitation workers. Survey instruments measuring hope, meaning in life, work engagement, and satisfaction with life were utilized.

RESULTS

Individuals working in a hospice care center have significantly higher levels of work engagement than their counterparts in rehabilitation. For both groups, hope was significantly related to subjective well-being. For hospice care but not rehabilitation workers, meaning in life was also related to subjective well-being. Multivariate analysis showed that hope and meaning in life were independent factors predicting subjective well-being in hospice care workers.

SIGNIFICANCE OF RESULTS

Hospice care workers are highly engaged in their work despite the challenging nature of their work. What characterizes these workers is a level of subjective well-being that is related to both meaning in life and hope. Maintaining a high level of subjective well-being may be an important factor in preventing burnout among those working in hospice care settings.

A Qualitative Study Examining the Illness Narrative Master Plots of People with Head and Neck Cancer

Background: There is a need to understand the common plots (master plots) of illness narratives for people who are treated for cancer. Improved insight would enhance therapeutic relationships and help reduce stress for health care professionals (HCPs). Aim: Identify and refine the most supported narrative master plots, which convey meaning for the tellers' lived experience from diagnosis to a year post-treatment for a group of Head and Neck Cancer (H&NC) patients. Method: A purposive sample of individuals with H&NC using a single qualitative interview was undertaken. A narrative analysis was used. Results: Eighteen people (57.8 years, six female and 12 male) with H&NC participated. The average time since treatment began was 10 months. Five master plots were identified: (1) The responsive and reflective narrative, (2) The frail narrative, (3) The recovery narrative, (4) The survive or die narrative and (5) The personal project narrative. Discussion: The identification of narrative master plots of people with H&NC enables HCPs to understand and prepare for the different stories and reactions presented to them. This is important to prevent people's reactions being labelled in restrictive ways. The implications of recognising the different experiences are discussed further within the manuscript. Research is needed to build on these findings to promote better patient-centred care in practice.

Narrative intervention: Stories from the front lines of oncology health care

This study examined the experiences of health care professionals who participated in monthly narrative oncology groups. Ten professionals participated in separate, semi-structured, face-to-face interviews. Using a qualitative research design, the transcriptions of the interviews were analyzed using a phenomenological approach. The analysis yielded descriptive information about the professionals' positive experiences of participating in narrative oncology sessions and provides insight into the importance of such a group through five themes: (1) Shared perspectives and bearing witness, (2) Comfort in confidentiality and a safe-space, (3) Group-care becomes self-care, (4) Writing gives structure, and (5) Patient stories. Implications for incorporating narrative intervention in an oncology setting are discussed in this paper.

Playing music improves well-being of oncology nurses

BACKGROUND

Nurses experience high levels of stress associated with the demands of their workplace. Anxiety and depression symptoms are common in this occupational group and the necessity of supportive actions is vital. This is especially true for nurses working in high intensity and demanding settings such as oncology units.

AIM

This study examined the effects of a music intervention on anxiety, depression, and psychosomatic symptoms of oncology nurses.

METHODS

Forty-eight oncology nurses, were randomized to either an intervention group (n = 22) attending four consecutive weekly 1-h music classes or a control group with no intervention (n = 26) who maintained their usual lifestyle habits, for one month. Intervention group played and improvised music using percussion instruments. Courses consisted of varied multitask exercises of progressive difficulty, sometimes involving team playing, or individual performances. Depression, anxiety, and physical symptoms were measured before and after the end of the intervention. Anxiety and depression were assessed with the Hospital Anxiety and Depression Scale. Psychosomatic symptoms were assessed with Pennebaker Inventory οf Limbic Languidness.

RESULTS

Anxiety, depression and psychosomatic symptoms significantly reduced for the intervention group at the end of the study. No statistical significant change was observed for the control group in any of the three psychological indicators.

CONCLUSION

The findings of our study highlight the fact that music can be a cost-effective resource in developing interventions to reduce stress and improve well-being. Playing music can be the next step for further investigation, since we already know that listening to music is beneficial.

Resilience and burnout status among nurses working in oncology

BACKGROUND

This study aimed to identify the resilience and burnout status of nurses working in the field of oncology.

METHODS

This descriptive study was conducted with 140 oncology nurses. The data were collected using a socio-demographic attributes form, Resilience Scale for Adults, and the Maslach's Burnout Inventory. Percentage ratios, mean and median values, Kruskal-Wallis test, Mann-Whitney U test, correlation analysis, and multiple stepwise linear regression analysis were used to evaluate the data.

RESULTS

The Maslach's Burnout Inventory total median score was 49.00. The emotional exhaustion median score was 24.00, the depersonalization median score was 9.00, and the personal accomplishment median score was 16.00. The Resilience Scale for Adults total median score was 134.00. The median resilience subscale scores, such as structural style, perception of future, family cohesion, self-perception, social competence, and social resources, were 16.00, 16.00, 24.00, 25, 23, and 31, respectively. A relationship existed between emotional exhaustion and perception of future; depersonalization and structured style and self-perception; and personal accomplishment and structured style, perception of future, and self-perception. Multiple stepwise linear regression analysis revealed a significant relationship between the number of years in the field and emotional exhaustion and depersonalization scores. Moreover, a significant relationship between structured style variables and personal accomplishment scores was observed.

CONCLUSIONS

This study demonstrated the relationship between burnout and resilience situations among the oncology nurses. The results can be used to plan individual and organizational interventions to increase resilience and reduce the experience of burnout by developing measures such as improving communication skills, providing education on stress management and coping strategies, using social resources, and organizing programs that provide psychological support.

Radiation Protection Knowledge, Attitude and Practice (RP-KAP) as Predictors of Job Stress Among Radiation Workers in Tehran Province, Iran

Background

In recent years, much attention has been paid to occupational stress, but relatively little or no research has been conducted on the influence of knowledge, attitude, and practice of radiation protection (RP-KAP) on job stress among radiation workers

Objectives

This study aims to assess job stress among health care workers in Iran who are occupationally exposed to radiation in order to determine the effects of KAP on self-protection against radiation on their job stress.

Materials and Methods

The population in this descriptive cross-sectional study comprised 670 healthcare workers, including 428 staff with a degree in radiology and 242 other medical personnel who were working in 16 hospitals affiliated with Tehran University of Medical Sciences (TUMS) in Tehran, Iran. The census method was used to sample the workers. In total, 264 staff with a degree in radiology and 149 other medical personnel completed the job content questionnaire (JCQ) and the RP-KAP questionnaire from May to November 2014.

Results

The prevalence rate of job stress was 22.5% based on calculation formulas and possible scores on the JCQ. Sex, RP-knowledge, attitude, practice, and in-service training predicted 41.8% of the variance in job stress. According to the results of the binary logistic regression, workers with higher scores on knowledge (OR = 0.82, 95% CI: 0.75 - 0.90), attitude (OR = 0.71, 95% CI: 0.63 - 0.82), and practice (OR = 0.78, 95% CI: 0.72 - 0.86) and those who had participated in training programs had significantly lower rates of job stress (OR = 0.51, 95% CI: 0.28 - 0.93).

Conclusions

The effects of RP knowledge, attitude, and practice on job stress were significant. In order to reduce job stress in radiation environments, ongoing training programs related to self-care and protection principles are recommended.

A cross-sectional study of stressors and coping mechanisms used by radiation therapists and oncology nurses: Resilience in Cancer Care Study

INTRODUCTION

Occupational stress and burnout are well-recognised experiences reported by cancer care workers. The aim was to describe the frequency and severity of potential stressors as well as the effectiveness of coping skills of radiation therapists (RTs) and oncology nurses (ONs), which make up the two largest occupational groups in cancer care.

METHODS

A questionnaire was distributed to RTs and ONs in two large tertiary hospitals in Queensland. Descriptive data regarding severity of potential stressors at home and work as well as the perceived effectiveness of preferred coping styles for each stressor was compared for each professional group. Respondents were asked questions about their personal circumstances and to also complete five standardised questionnaires measuring resilience, mental well-being, depression, anxiety and burnout.

RESULTS

There were 71 respondents representing a response rate of 26%. The types of stressors differed between the two groups but both reported that heavy workload was the most severe workplace stressor. RTs reported higher stressor and coping strategy frequency than ONs. There were no identifiable differences between RTs and ONs in the types or effectiveness of coping strategies employed at home or work. Mental well-being for both groups was inversely correlated with depression, anxiety and burnout and positively correlated with resilience.

CONCLUSIONS

RTs experienced higher mean scores for stressors and coping than ONs. There were no significant between-group differences for anxiety, depression, burnout, mental well-being or resilience.

Patients who die during palliative radiotherapy. Status survey

BACKGROUND AND PURPOSE

Palliative radiotherapy (RT) is routinely used in end of life care of patients with advanced malignancies; however, unnecessarily burdensome treatment shortly before death should be avoided. There is little knowledge on incidence and causes of intercurrent deaths during palliative RT.

PATIENTS AND METHODS

In this study death events among inpatients receiving palliative RT between January 2009 and December 2011 at this department were retrospectively analyzed. Among epidemiological factors, treatment schedule and chronology, latency and duration of treatment in relation to the actual survival were identified.

RESULTS

In this study 52 patients died during or shortly after palliative RT. Symptomatic bone metastases and brain metastases represented the most common RT indications. The general health status was poor with a median Karnofsky performance score of 50 %, RT was realized with a median single dose of 2.5 Gy to a median total dose of 30.5 Gy and was stopped prematurely in 73 % of patients. On average 53 % of the remaining lifetime was occupied by latency to starting RT. Once RT was begun the treatment duration required a median 64 % of the still remaining lifetime.

CONCLUSION

The majority of patients who died had explicitly adverse pre-existing factors and rarely completed RT as scheduled. Latency to RT and RT duration occupied more than half of the remaining lifetime.

Revisiting perceptions of quality of hospice care: managing for the ultimate referral

Hospice services provided in the final months of life are delivered through complex interpersonal relationships between caregivers, patients, and families. Often, service value and quality are defined by these interpersonal interactions. This understanding provides hospice leaders with an enormous opportunity to create processes that provide the optimal level of care during the last months of life. The authors argue that the ultimate referral is attained when a family member observes the care of a loved one, and the family member conveys a desire to receive the same quality of services their loved one received at that facility. The point of this article is to provide evidence that supports the methods to ultimately enhance the patient's and family's experience and increase the potential for the ultimate referral.

Meaning in bone marrow transplant nurses' work: experiences before and after a "meaning-centered" intervention

BACKGROUND

When a clinical culture emphasizes cure, as in bone marrow transplantation (BMT) services, BMT nurses commonly experience enormous stress when patients are suffering or dying. In this context, it is unclear what meanings BMT nurses experience in their work and how they find meaning and sustain hope, given conflicting responsibilities to patients.

OBJECTIVE

This study aimed to explore BMT nurses' experiences of meaning and hope and the effects of a meaning-centered intervention (MCI) on these experiences using qualitative methodology.

METHODS

Fourteen BMT nurses engaged in a 5-session MCI, with 7 members each participating in 2 groups. Semistructured qualitative interviews were conducted at 1 month before and after the intervention. Interpretive phenomenology guided data analysis.

RESULTS

The BMT nurses in the Princess Margaret Hospital experienced meaning in their involvement with their patients' suffering. The MCI seemed to inspire participants to engage more with patients and their suffering. Three subthemes reflected this influence: (a) greater awareness of boundaries between their personal and professional involvement, (b) enhanced empathy from an awareness of a shared mortality, and (c) elevated hope when nurses linked patients' suffering with meaning.

CONCLUSIONS

This study confirms that patients' suffering constitutes nurses' search for meaning and hope in their work. The MCI offers a way in which to actively support nurses in this process.

IMPLICATIONS FOR PRACTICE

Nurses can learn to be more responsive to patients' suffering beyond limits of cure. A minimal intervention, such as the MCI, supports BMT nurses in finding positive personal meaning and purpose in their otherwise highly stressful work culture.

Effect of music therapy on oncologic staff bystanders: A substantive grounded theory

Objective:

Oncologic work can be satisfying but also stressful, as staff support patients and families through harsh treatment effects, uncertain illness trajectories, and occasional death. Although formal support programs are available, no research on the effects of staff witnessing patients' supportive therapies exists. This research examines staff responses to witnessing patient-focused music therapy (MT) programs in two comprehensive cancer centers.

Method:

In Study 1, staff were invited to anonymously complete an open-ended questionnaire asking about the relevance of a music therapy program for patients and visitors (what it does; whether it helps). In Study 2, staff were theoretically sampled and interviewed regarding the personal effects of witnessing patient-centered music therapy. Data from each study were comparatively analyzed according to grounded theory procedures. Positive and negative cases were evident and data saturation arguably achieved.

Results:

In Study 1, 38 staff unexpectedly described personally helpful emotional, cognitive, and team effects and consequent improved patient care. In Study 2, 62 staff described 197 multiple personal benefits and elicited patient care improvements. Respondents were mostly nursing (57) and medical (13) staff. Only three intrusive effects were reported: audibility, initial suspicion, and relaxation causing slowing of work pace. A substantive grounded theory emerged applicable to the two cancer centers: Staff witnessing MT can experience personally helpful emotions, moods, self-awarenesses, and teamwork and thus perceive improved patient care. Intrusive effects are uncommon. Music therapy's benefits for staff are attributed to the presence of live music, the human presence of the music therapist, and the observed positive effects in patients and families.

Significance of results:

Patient-centered oncologic music therapy in two cancer centers is an incidental supportive care modality for staff, which can reduce their stress and improve work environments and perceived patient care. Further investigation of the incidental benefits for oncologic staff witnessing patient-centered MT, through interpretive and positivist measures, is warranted.

Factors Associated With Work Stress and Professional Satisfaction in Oncology Staff

Cancer care professionals work in a stressful environment, but it is not clear what factors contribute to this stress. We surveyed 60 oncology personnel on an inpatient unit and a palliative care unit regarding levels of perceived work stress and its potential contributors. Logistic regression analyses were performed to determine predictors of staff stress. A total of 63% of staff reported experiencing ``a great deal'' of stress at work, which was predicted by greater perceived workload (odds ratio = 32.2; P < .0001), insufficient time to grieve patients' death (odds ratio = 9.75; P = .0007), lack of institutional support (odds ratio = 0.16; P = .009), perceived lack of resources (odds ratio = 0.06; P = .007), and lack of control over the choice of workplace (odds ratio = 0.10; P = .03). Measures to address work-related stress should be included in the planning of cancer programs.