Rural unpaid caregivers' experiences in northern Aotearoa, New Zealand during the Covid-19 pandemic: A qualitative study.

OBJECTIVE: Rural unpaid caregivers experience different opportunities and challenges than their urban counterparts. Our aim was to understand rural unpaid caregivers' experiences of challenges and opportunities during the Covid-19 pandemic in New Zealand. SETTING: Rural northern New Zealand during the Covid-19 pandemic. PARTICIPANTS: A convenience sample of 10 unpaid rural caregivers, most supporting an older person living with dementia. DESIGN: A qualitative descriptive design. Data included interviews and online workshops, and a thematic analysis. RESULTS: Rural unpaid caregivers observed that some aspects of living in a rural context were helpful during the Covid-19 pandemic. However, tasks such as shopping and long-distance travel and communication (both telephonic and digital) became more complex. Abrupt changes to routine and closure of resources and support groups created challenges. Unpaid caregivers worried about what would happen if they were hospitalised themselves. There was a diversity of experience both across caregivers, of familiar routines and rural context as resources, increased challenges requiring resourcefulness to adapt, and experiences of crisis. Many experienced all three states at different times. CONCLUSION: This research provides valuable insights into challenges and opportunities experienced by rural unpaid caregivers during the Covid-19 pandemic and may help policy-makers and healthcare professionals develop improved emergency preparedness. Multilevel, multisector responses are needed to ensure effective health and social support and access to resources including health care, access to groceries and medication, transport, and communications (telephone and digital). Enhancing rural access to effective and inexpensive online services is particularly important, as is recognition of the value of rural sites or hubs of connection and social interaction.

Exploring the impact of e-learning modules and webinars on health professionals' understanding of the End of Life Choice Act 2019: a secondary analysis of Manatu Hauora - Ministry of Health workforce survey.

AIM: To explore the importance of health workforce training, particularly in newly regulated healthcare practices such as assisted dying (AD). This study aims to analyse the socio-demographic factors associated with health professionals' completion of the e-learning module and attendance at the two webinars provided by the New Zealand Ministry of Health - Manatu Hauora (MH) and whether completion of the e-learning module and webinars supported health professionals' understanding of the End of Life Choices Act 2019. METHOD: Secondary analysis of the MH workforce surveys conducted in July 2021. RESULTS: The study findings indicate that health professionals who are older, of Pakeha/European ethnicity and work in hospice settings are more likely to complete the e-learning module, while females are more likely to attend webinars. CONCLUSION: Despite low completion and attendance rates, the study highlights the positive association between training and health professionals' overall understanding of the Act. These results emphasise the need for enhancing training programmes to increase health professionals' knowledge and competence with AD. Furthermore, the research proposes focussing on healthcare practitioners in the early stages of their careers and not directly engaged in offering AD services, as well as Maori and Pasifika health practitioners.

Psychosocial well-being in Long-Term Care in the Wake of COVID-19: Findings from a Qualitative Study in New Zealand.

Drawing on Mason Durie's (1985) New Zealand Whare Tapa Wha model of health (spiritual, emotional, physical, and family domains), the goal was to link a model of well-being with the lived reality for long-term care residents and bereaved family members during COVID-19. Interviews were conducted with five residents and six family members of previous residents of one long-term care in one urban centre between July and September 2020. The increased demands imposed by the pandemic highlighted the gaps in well-being for residents and families. In particular, the inability to connect with family during COVID-19 restrictions reduced perceptions of well-being for residents. Study findings indicate that the provision of well-being for older adults and families in long-term care extends beyond the narrow bounds of the biomedical model. The Whare Tapa Wha model provides a valuable framework describing the holistic balance needed between the four health domains.

Health professionals' understanding and attitude towards the End of Life Choice Act 2019: a secondary analysis of Manatu Hauora - Ministry of Health workforce surveys.

AIM: To determine socio-demographic factors associated with health professionals' understanding of the End of Life Choice Act (the Act), support for assisted dying (AD), and willingness to provide AD in New Zealand. METHOD: Secondary analysis of two Manatu Hauora - Ministry of Health workforce surveys conducted in February and July 2021. RESULTS: Our analysis showed (1) older health professionals (age>55) had a better overall understanding of the Act than their young colleagues (age⁢35), (2) female health professionals were less likely to support and be willing to provide AD, (3) Asian health professionals were less likely to support AD compared to their Pakeha/European counterparts, (4) nurses were more likely to support AD and be willing to provide AD when compared to medical practitioners, and (5) pharmacists were more willing to provide AD when compared to medical practitioners. CONCLUSION: Several socio-demographic factors, including age, gender, ethnicity, and professional background, are significantly associated with health professionals' support and willingness to provide AD, with likely consequences for the AD workforce availability and service delivery in New Zealand. Future review of the Act could consider enhancing the roles of those professional groups with higher support and willingness to assist in providing AD services in caring for people requesting AD.

The challenges for health professionals delivering palliative care in the community during the COVID-19 pandemic: An integrative review.

OBJECTIVES: The growing demand for palliative care has been accelerated due to the COVID-19 pandemic. However, providing community-based palliative care was also more difficult to do safely and faced several challenges. The goal of this integrative review was to identify, describe, and synthesize previous studies on the challenges for health professionals delivering palliative care in the community during the COVID-19 pandemic. METHODS: Searches were carried out on the Ovid MEDLINE, CINAHL, PsycINFO, Social Care Online, PubMed, Embase, and Expanded Academic databases. Journals typically reporting palliative care and community health studies were also searched (Palliative Medicine, Journal of Pain and Symptom Management, and Health & Social Care in the Community). All articles were peer-reviewed and published in English between December 2019 and September 2022. RESULTS: Database and hand searches identified 1231 articles. After duplicates were removed and the exclusion criteria applied, 27 articles were included in the final review. Themes in the research findings centered on 6 interconnected categories. The challenges imposed by the pandemic (lack of resources, communication difficulties, access to education and training, and interprofessional coordination), as well as the varying levels of success of the health-care responses, impacted the well-being of health professionals and, in turn, the well-being and care of patients and families. SIGNIFICANCE OF RESULTS: The pandemic has provided the impetus for rethinking flexible and innovative approaches to overcome the challenges of delivering community palliative care. However, existing governmental and organizational policies require revision to improve communication and effective interprofessional collaboration, and additional resources are needed. A blended model of virtual and in-person palliative care delivery may provide the best solution to community palliative care delivery moving forward.

The contribution of generalist community nursing to palliative care: a retrospective case note review.

Background: There is a paucity of evidence regarding the contribution of generalist community nursing to palliative care. Aim: The aim of this study was to identity the proportion of patients referred to a generalist community nursing service who meet the criteria for palliative care need and explore key aspects of their management. Methods: A retrospective case note review of people known to a generalist community nursing service was undertaken to identify people with palliative care needs. Results: Of the 1284 people enrolled in the community nursing service, 21.1% (n=271) were identified as having palliative care needs, of which most (82.7%; n=224) had a non-cancer illness. However, palliative care need was largely unrecognised in the referrals to community nursing and there was little evidence of a palliative approach being integrated into nursing care. Conclusions: Nursing has a significant role in the provision of generalist palliative care in the community. However, research is needed to identify the barriers community nurses experience identifying needs and providing palliative care. A focus on education and support in implementing screening tools, which may assist community nurses in recognising needs and delivering palliative in the generalist setting, is urgently needed.

Intersectionality and nursing leadership: An integrative review.

AIMS AND OBJECTIVES: This review aimed to synthesise international research about how intersectionality has been used to explore issues within the nursing profession. The objectives were to determine which intersecting variables have been explored, how intersectionality has been operationalised, and the implications for nursing leadership. BACKGROUND: Barriers to health system leadership created at the intersection of gender, race, ethnicity, professional cadre and other socially constructed categories exist in the health workforce. Consequently, an intersectionality paradigm has been recommended to explore power, privilege and oppression issues in the nursing profession. DESIGN: An integrative systematic review method was selected for its ability to include diverse methodologies. The review complies with the PRISMA guidelines for reporting systematic reviews. METHOD: The search terms nurs* nurses nursing AND Intersectionality intersectional intersectionalism, intersect were used in December 2021 to search the Cumulative Index to Nursing and Allied Health Literature (CINAHL Plus) PsycINFO, PubMed, Ovid, ProQuest and the first ten pages of Google Scholar from 2011 to 2021. Directed content analysis was applied to the data. RESULTS: Access to education, absence of expectations as a career and patriarchal structures support male nurses into positions of leadership in healthcare systems. Intra-group differences highlight the paradox of homogenous categories for ethnicity and gender. Being a member of an ethnic minority group hinders career progression regardless of gender. The aftereffects of colonisation exist within the nursing space. CONCLUSIONS: This review is the first to synthesise research using intersectionality to explore the impact of socially constructed identities on nursing leadership. There is a dearth of evidence specific to this topic, ignoring the diversity within this professional group. Future research should include intersectionality to discover how social categories empower or impede a nurse's career progression to leadership roles. RELEVANCE TO CLINICAL PRACTICE: An intersectionality paradigm can encourage nurses to attend to issues of power, privilege and oppression in the profession and their practice.

Health equity and wellbeing among older people's caregivers in New Zealand during COVID-19: Protocol for a qualitative study.

BACKGROUND: Knowledge of the challenges unpaid caregivers faced providing care to older people during the COVID-19 pandemic is limited. Challenges may be especially pronounced for those experiencing inequitable access to health and social care. This participatory action research study, located in New Zealand, has four main objectives, (i) to understand the challenges and rewards associated with caregiving to older care recipients during the COVID-19 pandemic restrictions; (ii) to map and collate resources developed (or mobilised) by organisations during the pandemic; (iii) to co-produce policy recommendations, identify useful caregiver resources and practices, prioritise unmet needs (challenges); and, (iv) to use project results in knowledge translation, in order to improve caregivers access to resources, and raise the profile and recognition of caregivers contribution to society. METHODS AND ANALYSIS: Maori, Pacific and rural-dwelling caregivers to 30 older care-recipients, and 30 representatives from organisations supporting caregivers in New Zealand will be interviewed. Combining data from the interviews and caregivers letters (from an archive of older people's pandemic experiences), framework analysis will be used to examine the interrelated systems of the human ecological model and the impact on caregiving experiences during the pandemic. Resources that service providers had created or used for caregivers and older people will be collated and categorised. Through co-production with caregivers and community partners we will produce three short films describing caregivers' pandemic experiences; identify a suite of resources for caregivers to use in future events requiring self-isolation, and in everyday life; and generate ideas to address unresolved issues.

COVID-19 and hospice community palliative care in New Zealand: A qualitative study.

Within the context of an ageing population and the added challenges posed by COVID-19, the need to optimise palliative care management in the community - the setting where a significant proportion of people prefer to die - cannot be underestimated. To date, there has been a dearth of research exploring community palliative care delivery during the pandemic. This study aimed to explore the impact of and response to COVID-19 for hospice community services in Aotearoa/New Zealand. Eighteen structured interviews were conducted (10 February-18 August 2021) with healthcare professionals from sixteen purposively sampled community hospices from New Zealand regions according to the number of COVID-19-positive patients per 100,000 inhabitants (low, medium and high) with oversampling of high prevalence areas. Two overarching themes emerged 'challenges' and 'adaptations'. Each theme had several subthemes related to service delivery in communication, visiting, allied health team collaboration and volunteer services. Adaptations involved adjusting official health advice to the local context, increased use of telehealth, reducing infection risk during in-home visits through triaging of cases, division of the workforce into teams and repurposing volunteers' services. Despite these adaptations, challenges remained, including increased workload pressures for staff and an absence of the human touch for patients and families. Implications for hospice practice and recommendations for future research are discussed. Governments must acknowledge the essential contribution of hospice to the COVID-19 pandemic and ensure that these services are incorporated into the healthcare system response.

The views of Aotearoa/New Zealand adults over 60 years regarding the End of Life Choice Act 2019.

This study described the views of older New Zealand adults toward assisted dying and specifically the End of Life Choice Act (2019), an Act making assisted dying legal. An anonymous postal and online survey of 636 adults 60 years and older was conducted. The majority of respondents did not support legalization (85.7%), while 8.8% were in favor (5.5% did not specify a view). Weighted binary logistic regression indicated that the odds of support for legalization were lower in those respondents with a religious affiliation (OR = .020, S.E. = 0.60, p = .00), and there were 2.66 times greater odds in those identifying as male (S.E. = 0.34, p = .005). On the other hand, those respondents under 65 years had increased odds of supporting legalization (OR = 1.89, S.E. = .029, p = .045). Results indicate that most participants were concerned about potential abuses and coercive practices if assisted dying became legally available in New Zealand.

Difficulties in navigating the intersection of generalist and specialist palliative care services: A cross-sectional study of bereaved family's experiences of care at home in New Zealand.

A generalist-specialist model of palliative care is well established as a framework for the provision of community care in resource-rich countries. However, evidence is lacking regarding how the model is experienced by family carers and the extent to which access to both generalist and specialist palliative care is equitable. A cross-sectional postal survey was undertaken to explore bereaved family's experiences of generalist palliative care and its intersection with hospice services in the last 3 months of life. A modified version of the Views of Informal Carers-Evaluation of Services survey was sent to 4,778 bereaved family. Data were collected between February 2017 and October 2018. Chi-square was utilised to identify factors that impacted on experiences of generalist palliative care; analysis of free text data comprising 45,823 words was undertaken using a directed content analysis approach. Eight hundred and twenty-six questionnaires were returned (response rate = 21%). Seventy per cent of people (n = 579) spent some time at home in the last 3 months prior to death. People who received support from hospice were more likely to receive support from multiple other services. Those who received no community services were less likely to feel supported by their general practitioner, less likely to spend the last 2 days of life or die at home. Feeling supported had a strong association with services working well together, being involved in decision-making and being aware of the poor prognosis. The provision of palliative care is complicated by a lack of integration with specialist palliative care and may be the basis of continuing inequities in the provision of community care at the end of life. The assumption at a policy level that "generalists" are willing and able to play a key role in palliative care provision needs to be further challenged.

InterRAI assessments: opportunities to recognise need for and implementation of palliative care interventions in the last year of life?

OBJECTIVES: To explore how interRAI assessments could be used to identify opportunities to integrate palliative care into a plan of care. METHODS: A population-based, cross-sectional design using unique identifiers to link deaths with a national interRAI database. Data were analysed using logistic regression models and chi-square tests. RESULTS: A total of 4869 people died over a 12-month period in one district health board area; 50.9% (n = 2478) received one or more interRAI assessments in the year before death. Diagnosis impacted on the type and timing of interRAI assessments and the recognition of end-stage disease. CONCLUSION: People in the last year of life experience frequent interRAI assessments. There are opportunities to identify people who might benefit from a palliative care approach. Future research is needed to understand how interRAI assessors can be supported in the application of assessment items related to palliative care.

The impact of intersectionality on nursing leadership, empowerment and culture: A case study exploring nurses and managers' perceptions in an acute care hospital in Aotearoa, New Zealand.

AIM: This study determines whether the culture within an acute care hospital empowers 'all' nurses to be leaders by exploring intersectionality and nursing leadership in the context of the social environment. BACKGROUND: Nurses practice leadership in their day-to-day activities as clinical leaders alongside traditional roles of management and leadership. However, some nurses do not acknowledge nursing work as leadership activity, nor is it seen so by others where hierarchical leadership approaches remain prevalent. Social constructs of gender and race are barriers to accessing formal leadership positions for some, while dominant power structures such as class diminish the value of bedside nursing work. Unexplored is the impact of the intersection of these and other social identities on nurses being leaders. DESIGN: An embedded case study design. METHODS: Thirty-one participants participated in semi-structured interviews. Four levels of analysis including inductive and deductive approaches were applied to the data. The research complied with COREQ guidelines for reporting qualitative research. RESULTS: This study shows nurses do not identify themselves as leaders without an associated title and the pathway to leadership varies depending on intersecting social constructions. CONCLUSION: The impact of the organisational structures and the experience of navigating intersecting social constructions on nurses being leaders goes unseen, privileging some while disadvantaging others. RELEVANCE TO CLINICAL PRACTICE: Health organisations need to be aware of intersectionality in the workplace and explore equity in their structures to be genuinely empowering. Nursing leadership must examine strategies that challenge and decolonise the nursing profession. Bedside nurses should be given more power and respected as leaders of the patient experience, achievable through a renewed emphasis on the fundamentals of care and resonant leadership, which can neutralise a culture of managerialism. Intersectionality can inform the development of new nursing leadership roles that enable nurses to remain clinically active, widening opportunities.

Proactive primary care model for frail older people in New Zealand delays aged-residential care: A quasi-experiment.

BACKGROUND/OBJECTIVES: To determine the effect of a proactive primary care program on acute hospitalization and aged-residential care placement for frail older people. DESIGN: Controlled before and after, and controlled after only quasi-experimental studies, with a comparison group created via propensity score matching. One-year follow-up. SETTING: Nine general practices in Auckland, New Zealand. PARTICIPANTS: Community-dwelling people aged 75 and older identified as at increased risk of hospitalization. One thousand and eighty five patients are compared with 3750 comparison patients matched by propensity score based on known risks. INTERVENTION: Primary healthcare based, registered nurse-led, comprehensive geriatric assessment, goal-setting, care planning, and regular follow-up. Patients were also provided self-management education, health and social care navigation, and transitional care for hospital discharges. Practices received program support, workforce development, and mentoring of primary healthcare nurses by gerontology nurse specialists. MEASUREMENTS: Outcomes from routinely collected administrative data. Primary: aged-residential care placement. SECONDARY OUTCOMES: acute hospitalization, mortality, and other health service utilization. RESULTS: Aged-residential care placement (odds ratio [OR] 0.66, 95% confidence interval (CI) = 0.48-0.91) and mortality (OR 0.66, 95% CI = 0.49-0.88) were significantly lower over the first year in Kare patients compared with matched controls. There was no difference in acute hospitalization (+0.06 admissions per year, 95% CI = -0.01-0.13). Support service use (allied health therapists and assessment for social support) was increased, and emergency department use decreased. CONCLUSION: The Kare participants had lower aged-residential care placement and mortality in the first year, but no decrease in acute hospitalization. Because the design is nonexperimental caution is required in interpreting these results.

Psychological support requirements of haematological cancer survivors: how can health professionals meet their needs?

Complex and intensive treatment may lead to psychosocial issues for haematological cancer survivors, which may endure after treatment. Psychological support is important for cancer survivors but not always available. This study aimed to determine the health professional psychological support needs of post-treatment haematological cancer survivors, through the use of across-sectional survey. Chi-Square analyses were used to calculate the differences in need for psychological support. Open text responses were analysed using quantitative content analysis. Four hundred and nine questionnaires were completed. Around quarter (24.6%) of participants reported needing more psychological support from a health professional, especially those who were aged 18-39, females, 'Other' ethnicity, single, living with other family/roommates, unemployed/on sick leave, suffering significant distress, and those with low/moderate social support. The majority of those desiring more support preferred it from a psychologist/counsellor (58.3%), or a haematologist (39.3%). Haematologists are a regular point of contact for these survivors and not only have the opportunity to discuss psychological issues with patients but to determine who needs referring to further psychological treatment. Furthermore, the a number of participant's reporting theneed for extra psychological support from a psychologist/counsellor means it is imperative that these services are available and known to those requiring them.

Palliative care delivery in residential aged care: bereaved family member experiences of the Supportive Hospice Aged Residential Exchange (SHARE) intervention.

BACKGROUND: The supportive hospice aged residential exchange (SHARE) is a new model of palliative care education that has been designed for residential aged care. The goal of SHARE is to help clinical staff improve palliative care within residential aged care facilities and to improve specialist palliative care nurses' knowledge and skill to care for frail older people. METHOD: The experiences of 18 bereaved families concerning the palliative care journey (both at the start and finish of a one-year implementation of SHARE) were explored using semi-structured interviews. RESULTS: Three themes were important to bereaved families' experience: communication with staff, systems of care, and hospice involvement. Sub-themes indicating changes in these three components of care between the start and finish of SHARE was identified. A fourth theme highlighted challenges (relationship with GP, staff shortages, and turnover) that continued across SHARE. CONCLUSION: Findings indicated that SHARE benefited families (improved communication and support) through the end of life journey of their relatives, but challenges remained.

Factors associated with overall satisfaction with care at the end-of-life: Caregiver voices in New Zealand.

In New Zealand, as in other industrialised societies, an ageing population has led to an increased need for palliative care services. A cross-sectional postal survey of bereaved carers was conducted in order to describe both bereaved carer experience of existing services in the last 3 months of life, and to identify factors associated with overall satisfaction with care. A self-complete questionnaire, using a modified version of the Views of Informal Carers - Evaluation of Services (VOICES) instrument was sent to 4,778 bereaved carers for registered deceased adult (>18yrs) patients in one district health board (DHB) for the period between November 2015 and December 2016. Eight hundred and twenty-six completed questionnaires were returned (response rate = 21%). The majority of respondents (83.8%) rated their overall satisfaction with care (taking all care during the last 3 months into account), as high. However, satisfaction varied by care setting. Overall satisfaction with care in hospice was significantly higher compared to other settings. Additionally, patients who died in hospice were more likely to be diagnosed with cancer and under 65 years of age. The factors associated with overall satisfaction with care in the last 2 days of life were: caregiver perceptions of treatment with dignity and respect; adequate privacy; sufficient pain relief and decisions in line with the patient's wishes. A more in-depth exploration is required to understand the quality of, and satisfaction with, care in different settings as well as the factors that contribute to high/low satisfaction with care at the end-of-life.

Provision of palliative and end-of-life care in New Zealand residential aged care facilities: general practitioners' perspectives.

This exploratory study examined general practitioners' (GPs) perspectives on delivering end-of-life care in the New Zealand residential aged care context. A general inductive approach to the data collected from semi-structured interviews with 17 GPs from 15 different New Zealand general practices was taken. Findings examine: (1) GPs' life experience; (2) the GP relationship with the facilities and provision of end-of-life care; (3) the GP interaction with families of dying residents; and (4) GP relationship with hospice. The nature of the GP relationship with the facility influenced GP involvement in end-of-life care in aged care facilities, with GPs not always able to direct a facility's end-of-life care decisions for specific residents. GP participation in end-of-life care was constrained by GP time availability and the costs to the facilities for that time. GPs reported seldom using hospice services for residents, but did use the reputation (cachet) associated with hospice practices to provide an authoritative buffer for their end-of-life clinical decisions when talking with families and residents. GP training in end-of-life care, especially for those with dementia, was reported as ad hoc and done through informal mentoring between GPs.

What factors predict the confidence of palliative care delivery in long-term care staff? A mixed-methods study.

BACKGROUND: Research has indicated that clinical staff in long-term care often lack self-confidence in palliative care delivery, particularly at the end of life. GOALS: (a) To examine the contribution of age, palliative care education, palliative care work-related experience and psychological empowerment to palliative care delivery confidence and (b) to explore the social reality shaping those factors for long-term care staff. DESIGN: Explanatory sequential design. SETTING: Twenty long-term care facilities in two district health boards in New Zealand. PARTICIPANTS: Phase 1:139 clinical staff. Phase 2:46 clinical staff who provided care in the last month of a residents' life. METHODS: Phase 1: Cross-sectional survey. Phase 2: Individual semi-structured interviews. RESULTS: Phase 1: Previous experience (ß = .319) and psychological empowerment (ß = .311) contribute most to predicting an increase in palliative care delivery confidence. Phase 2: Four factors underlay palliative care delivery confidence, (a) mentorship by hospice nurses or colleagues (b) contextual factors (organisational culture, resources and experience), (c) maturity and (d) formal education. CONCLUSION: Organisational leadership should use multiple strategies (e.g. power-sharing, increased opportunities for mentorship) to improve staff palliative care delivery confidence. IMPLICATIONS FOR PRACTICE: This study adds to the literature in understanding the predictors of palliative care delivery confidence specific to long-term care staff. The results indicate that educational interventions must be contextually appropriate to achieve sustainable improvements in palliative care confidence and ultimately in resident care at the end of life.