The impact of uncertainty on bereaved family's experiences of care at the end of life: a thematic analysis of free text survey data.

BACKGROUND: Inequities in the provision of palliative care for people with cardiac disease have been well documented in the literature. Despite experiencing significant palliative care needs, those with cardiac disease are less likely to be referred to specialist palliative care services and more likely to die in a hospital when compared to those with cancer. The unpredictable trajectory of heart failure has been identified as a key barrier to providing palliative care with many people experiencing a long period of stability with appropriate medical treatment. However, as the disease progresses and cardiac function deteriorates, exacerbations of acute decompensation can lead to what is often perceived to be 'sudden' death. The aim of this study is to explore the impact of uncertainty on how death is remembered by bereaved family members of people with heart disease. METHODS: Thematic analysis of free text collected during a postal survey of bereaved family's experiences of healthcare services in the last 3 months of life using the New Zealand version of the VOICES questionnaire was undertaken. Data was analysed using a three-dimensional conceptual framework of "scientific uncertainty". RESULTS: Eight hundred and twenty-seven completed questionnaires were received of which 12.6% (n = 105) indicated that they had cared for someone at the end of life with cardiac disease. Experiences of uncertainty were found to have a significant impact upon bereaved family. Four key themes were identified; distrust in healthcare professionals, stories left incomplete, loss, regret and missed opportunity and disempowerment. CONCLUSIONS: This study highlights the ongoing impact on bereaved family when uncertainty is not made explicit in conversations regarding end of life for people with heart disease. Timely and sensitive conversations regarding the uncertainty of when death may occur is an important factor in ensuring that bereaved family are not left with unresolved narratives. Reframing how we think and talk about uncertainty in end of life care is important, as clinicians' uncertainties may not always reflect or match up with families' uncertainties. Being explicit about our inability to be certain about the timing of death may thus lead to a more positive and complete experience for bereaved family.

Health Professionals' Engagement With Email-Enabler or Disrupter?

The use of email is an internationally recognized and accepted method to communicate information in an asynchronous manner. Yet, despite its ubiquitous use, there is evidence that there are differences in the degree of engagement with and perceived value of email as legitimate work within the healthcare setting. A lack of engagement with email could have consequences on the care of patients if email communication is not read or responded to by the intended recipient. The purpose of this study was to understand the email practices of health professionals within a hospital setting, including their interactions, experiences, and thoughts and ideas for sharing information in the future. Four focus groups (total number of participants, 30) were conducted in 2015 and 2016 using an Appreciative Inquiry model to focus on the use of email. Data were thematically analyzed, with three overarching themes identified: professional practice, workforce self-care, and shaping the future using technology. Overall, email was perceived as a less important function within a health professional's everyday clinical practice; however, this differed depending on their role. The health professionals' use of email ranged from very little engagement to what could be judged as over-engagement, all of which have implications for healthcare organizations who view email as a legitimate work task and a key way to communicate.

Older people's experiences of nurse-patient telephone communication in the primary healthcare setting.

AIM: To determine which aspects of primary nurse-patient telephone communication are viewed positively or negatively in terms of meeting the older persons' needs. BACKGROUND: Health professionals are increasingly being called on to develop different ways of working and increase their capacity to meet the needs of an ageing population. In some countries, telephone communication between primary nurses and patients in General Practice is already seen as a routine practice, but determining the value of this type of communication as a specific health service needs more understanding. DESIGN: A qualitative exploratory study as the aim was to explore the older person's experiences. METHODS: Semi-structured interviews were conducted with 21 older people from General Practices in New Zealand during 2014-2015. Thematic analysis was informed by a constructivist grounded theory approach. FINDINGS: The overarching theme was the difficulties older people face in making decisions about whether to contact a health professional by telephone and whether this should be the Primary nurse. Accounting for some of their symptoms as age related added to the uncertainty of decision-making. Importantly, some older people were not raising concerns e.g. emotional state. CONCLUSION: Decision-making by older people around treatment seeking is complex. Increasing the awareness of the nurse role in the General Practice is integral to creating a health system which will meet the needs of a growing older population. Primary care practices can review their systems to better inform older people how the nurse-telephone role as a specific health service works and what they can expect when using this service.

On-line health seeking activity of older adults: an integrative review of the literature.

The internet is increasingly used to provide health information. Supporting older people to access on-line health information requires understanding their current usage and possible barriers and facilitators. Methods involved searching three databases. Inclusion criteria were: (i) articles published within 10 years; (ii) people aged >65; (iii) explored reasons for older people accessing on-line health information and (iv) in English. Eight articles met these criteria. Older people use on-line health information to learn about a disease, medication, treatment, or healthy living. Factors influencing usefulness of on-line health information included demographics, health status, trust in the information, lack of skills using the internet and attitudes of health professionals. Findings indicate that while older people access on-line health information there are barriers: Low trust, financial barriers, lack of familiarity with the internet and low health literacy levels. Implications for nursing include working in partnership with older people to assist them to identify appropriate on-line information.

What are the factors that influence the delivery of smoking cessation advice in critical care?

BACKGROUND: The world's leading cause of preventable deaths, diseases and disabilities is smoking. Hospitalization can provide an opportunity for smokers to quit. Previous research found that smokers make up a high percentage of patients admitted to intensive care. Health care professionals working in critical care environments can make a valuable contribution to this public health issue by providing smoking cessation advice. AIM: To identify factors that inhibit and facilitate the delivery of smoking cessation advice by nurses and doctors in critical care settings. DESIGN: Quantitative design using an online survey. METHODS: This research was a single centre study carried out in a large tertiary hospital. Study sites were two adult critical care departments including a 14-bed general intensive care and a 16-bed cardiovascular intensive care unit. The target population for this research was the nursing and medical staff working in adult critical care environments. RESULTS: The data suggests that doctors and nurses have a good understanding of the complications related to tobacco use and also have education on smoking cessation. Additionally the data suggest that doctors and nurses at the study sites generally have positive attitudes towards smoking cessation. Patient acuity and competence were concerns raised in relation to the delivery and effectiveness of smoking cessation advice in critical care environments. CONCLUSIONS: The recovery phase following critical illness might be an opportunity to provide cessation advice. This could include focusing cessation advice efforts on awake, orientated and extubated patients. Further research might be required to confirm this. RELEVANCE TO CLINICAL PRACTICE: The provision of smoking cessation advice is an on-going World Health Organization and New Zealand Government priority and all parts of the health sector need to provide responses. However, responses need to be adapted to the specific context such as the unique challenges of critical care.

New Zealand palliative care nurses experiences of providing spiritual care to patients with life-limiting illness.

BACKGROUND: Internationally it is recognised that providing spiritual care is essential to reduce spiritual distress, particularly in patients who are facing a life-limiting illness. AIM: This study sought to explore palliative care nurses experiences providing spiritual care to their patients who are facing a life-limiting illness. METHOD: This study used a qualitative approach: interviews took place with nine nurses working across three hospices in New Zealand in 2013. FINDINGS: Nine palliative care nurses participated in the study. Their average age was 53 years and palliative care experience ranged from 3-22 years, with an average of 9 years. The narrative descriptions of nine palliative care nurses were demonstrated under the categories of the assessment of spiritual needs: recognition of spiritual distress, provision of spiritual care and documentation of spiritual care. Additionally, eight sub-categories: individuality and respect; connection; love and compassion; meaning, touching and presence; communication; divine-related spiritual care provision and referral; death preparation and post-modern spiritual care were identified under the category of provision of spiritual care. CONCLUSION: There are challenges in identifying and defining spiritual distress and there is complexity in the provision of spiritual care. However, for the nurses in this study, focusing on the individual patient and developing a relationship that enabled the patient's unique spiritual needs to be met was highly valued. Creating a culture where nurses, and other health professionals involved in the patient's care, share their experiences of spiritual care provision and discussion about how this can be documented is needed.

Working with older people with multiple long-term conditions: a qualitative exploration of nurses' experiences.

AIMS: (1) to generate in-depth insights into how nurses are working with older people with multiple long term conditions; (2) to gain an understanding of how nurses perceive professional patient navigation; and (3) to explore the barriers and facilitators to nurses adopting a navigation role in the context of Primary Health Care practice. BACKGROUND: Internationally, Primary Health Care has been identified as the main navigation point for older people with multiple long term conditions. Navigation models have been developed in cancer care but there is a lack of research in the context of Primary Care. There is also little evidence about the extent to which current work patterns of nurses providing care for this patient group fit with professional patient navigation models. DESIGN: A descriptive exploratory qualitative study. METHODS: Semi-structured audio recorded telephone interviews were conducted in 2012 with nurses in New Zealand who were working with older people with multiple long term conditions (n = 42) Interviews were transcribed verbatim and entered into Nvivo 9 for thematic analysis. FINDINGS: The key themes represent patterns of nursing work as; system work, relationship work and patient work. While nurses lacked a coherent understanding of patient navigation as a concept, the way they worked had some elements in common with professional navigation models. CONCLUSION: Further research involving older people in co-designing patient navigation approaches in Primary Health Care is needed to inform these types of service development and translate action from existing health policy.

A qualitative study of nurses' clinical experience in recognising low mood and depression in older patients with multiple long-term conditions.

AIMS AND OBJECTIVES: To explore how nurses' recognise depression in older patients with multiple long-term conditions and the strategies they use to support the patient. BACKGROUND: Depression decreases an older person's quality of life and sense of wellness, and increases functional impairment. The positive role of nurses working with patients with long-term conditions is now being recognised internationally; however, there is a gap in the research about how nurses recognise depression in older patients and how this impacts on their practice. DESIGN: This is a qualitative study informed by a constructivist grounded theory approach. METHODS: In-depth telephone interviews were conducted with 40 nurses working in geographically diverse areas in New Zealand. RESULTS: Having the conversation with older patients about their low moods, or specifically about depression was not something that all the nurses had, or felt they could have. While some nurses knew they could provide specific advice to patients, others believed this was not their responsibility, or within the scope of their role. CONCLUSION: Faced with an increasing number of older people with long-term conditions, one of which maybe depression itself or as a result of living with other long-term conditions, ongoing monitoring and support pathways are necessary to prevent further decline in the older person's quality of life and well-being. RELEVANCE TO CLINICAL PRACTICE: Nurses in primary health care can build on current knowledge and skills to increase their capability to promote 'ageing well' with older people who have long-term conditions and depression.

Patients' experiences of ongoing palliative chemotherapy for metastatic colorectal cancer: a qualitative study.

BACKGROUND: Colorectal cancer is the second most common cause of cancer death in New Zealand. With new chemotherapy regimens, patients with metastatic colorectal cancer are now living longer with the condition and its treatment. AIM: This study aimed to explore patients' experiences of extended palliative chemotherapy for metastatic colorectal cancer. METHODS: A convenience sample of 10 outpatients who had been receiving palliative chemotherapy for more than 12 months from a teaching hospital and regional cancer centre in New Zealand participated in face-to-face semi-structured interviews. The data was analysed using a general inductive approach. FINDINGS: Three key themes were identified: the importance of relationships, presenting a positive face, and life is for living. The importance of interpersonal relationships with health professionals and a sense of comradery with other chemotherapy patients positively affected the patients' experiences of treatment. Positivity was a key coping strategy that also has negative implications as patients may not reveal their concerns and needs. CONCLUSION: The key to improving the care of people with advanced cancer is understanding their experiences of care. Communication between the patient, family, and health-care team ensures assumptions that misinterpret attributes of positivity are not made.

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.

Organizational factors to optimize mental health nurses' wellbeing in the workplace: An integrative literature review.

Mental health nursing is a privilege and a rewarding profession. There has been a call for transformational change in mental health services to improve outcomes for the people of New Zealand, with mental health nurses integral to this. However, with predicted nursing shortages, high levels of burnout, and increasing demands in the workplace, an organizational focus on wellbeing for mental health nurses is needed to sustain the workforce, implement change and improve outcomes for people using mental health services. An integrative review of the literature was undertaken to explore how organizations can optimize mental health nurses' wellbeing in the workplace and to identify measures for organizations to support mental health nurses' wellbeing with a focus on New Zealand. Seven articles were included in this review after a search, data extraction and evaluation. Data were synthesized and categorized using thematic analysis. The findings indicate organizations can invest in several initiatives to enhance mental health nurses' wellbeing in the workplace. These include professional development, skills to build resilience, enabling time to reflect on practice, enhancing professional supervision, having the right managerial support and focusing on individual's strengths. Organizations need to prioritize mental health nurses' wellbeing by embedding the practical strategies this review identified and by addressing organizational barriers to wellbeing. Organizations should consider implementing multileveled organizational wellbeing initiatives to nurture and grow the New Zealand mental health nursing workforce which in turn will contribute to quality care and enable mental health nurses to have long meaningful careers. Time, investment and resources are essential for these initiatives to be effective.

Nursing students' reactions to a graphic novel: A multi-national descriptive qualitative study.

BACKGROUND: Undergraduate nursing programme teaching and learning methods and content must evolve to meet the changing evidence base, healthcare context and needs of new generations of nurses. Art-based and narrative methods have been employed to help student nurses explore complex issues, including patient experiences of health and illness, person-centred care and social determinants of health. One creative visual teaching tool is the graphic novel. However, little is known about student perceptions of graphic novels and how they facilitate student nurses' reflection, engagement and learning. Gaining such an understanding may be of especial value for teaching Generation Z students who are used to interacting with complex visual imgery and prefer alternatives to text-heavy documents. OBJECTIVE: The objective was to explore student nurses responses to Vivian, and graphic novels in general, as teaching resources in undergraduate nursing curricula in England, Sweden, and Aotearoa New Zealand. DESIGN: A social constructionist critical framework informing a descriptive qualitative study. SETTING AND PARTICIPANTS: Undergraduate nursing students in Sweden, England, and Aotearoa New Zealand. METHODS: Data were collected using focus groups and semi-structured interviews. Braun & Clark's method for thematic analysis was used to analyse the data. RESULTS: Three themes were developed: 1) reflections on clinical practice, including reflections on palliative care, holistic care for older people and communication between patients and staff; 2) graphic novels' usefulness as a teaching resource, in which students regarded them as an alternative way to learn; and 3) Vivian as a form of the graphic novel. CONCLUSION: The graphic novel Vivian helped nursing students engage in critical reflection and with challenging theoretical concepts. It, and graphic novels in general offer an alternative to print-based texts, which may heighten their appeal to Generation Z learners.

'Making sense': nurses' experiences of changing practice in caring for dying patients in New Zealand.

AIM: To explore nurses' experiences of a top-down change that involved the introduction of the Liverpool Care Pathway for the Dying Patient (LCP). METHODS: Using a qualitative design, two focus groups were conducted with a total of ten nurses and five semi-structured individual interviews were conducted with senior nurse managers. FINDINGS: The nurses viewed their experience with the LCP positively, highlighting an improvement in their knowledge base regarding care of the dying. 'Making sense' was a key theme that reflected how the nurses attempted to manage the impact of the change on their own practice and on the nursing team. CONCLUSION: Organisations need to invest skilled manpower, time, and resources into supporting nurses in their transitions. The benefits of such investment are an increased likelihood of implementing evidence-based care and sustained practice and organisational change. For patients and their families and friends this investment will result in tangible improvements in the delivery of treatment and care at a time in their lives when they are most vulnerable.

Navigating the pathway to ceasing driving-A voyage of discovery.

BACKGROUND: Ceasing driving for older people is a life transition and can be associated with a sense of loss and decreased wellbeing. Nurses can play a key role in supporting the older person to manage the transitions, especially as the work involved in ceasing driving is often hidden. For example, finding alternative and accessible means of travel and maintaining mobility. Travel itself can be viewed as essential, for example attending health appointments and shopping. Discretionary travel may not be viewed as essential, but provides an important means of maintaining activity and social connection. METHOD: A case study is presented of Mike's journey in ceasing driving. The concept of transition helps in co-creating with Mike his journey of discovery. Semi-structured interviews took place with Mike over a six-month period and a journey pathway created, which was subject to further iterations during subsequent interviews. RESULTS: Ceasing driving involves a number of transitions encompassing a series of losses, managing uncertainty, problem-solving and learning new skills. Being able to access and adapt to maintain mobility and travel are influenced by structural and environmental barriers. CONCLUSION: The World Health Organization's strategy to create age-friendly cities and communities is admirable. Like any other strategy this is a long-term plan, and in meantime action needs to happen to support older people in ceasing driving and creating a non-driving life and limit a decrease in well-being. Starting conversations on transitional travel planning is proposed, with nurses playing a central role in making this process happen.

Resilience and Burnout in Pediatric Nurses in a Tertiary Children's Hospital.

PURPOSE: To identify levels of burnout and resilience in pediatric nurses in a tertiary children's hospital in New Zealand. METHODS: Registered nurses providing pediatric care participated in a survey that included the Connor-Davison resilience scale and Maslach burnout scale. Nurses identified specific factors related to workload stress and strategies for enhancing resilience. RESULTS: Participants were 197 nurses. We found low levels of resilience and high levels of burnout, although personal accomplishment scores were high. Nurses with <10 years of experience who worked >40 hours per week had significantly higher levels of emotional exhaustion compared with those who had >10 or more years of experience or worked <40 hours per week. There were differences in resilience levels based on years of practice and hours worked. Levels of depersonalisation were higher in different ethnic groups. CLINICAL IMPLICATIONS: Burnout remains a significant problem for pediatric nurses. Job demands are likely to rise with the increased complexity of children with long-term conditions and families requiring support. Developing supportive plans to strengthen resilience and limit burnout are required. Further research is needed on how organizations can foster resilience practices and limit burnout, nurses feeling emotionally exhausted, reducing depersonalisation, and enhancing feelings of personal accomplishment. Nurse leaders can role-model positive resilience practices when engaging their teams in open conversations about preventing or reducing burnout.

Clinician knowledge of driving restrictions following a stroke event.

AIM: To investigate the knowledge and practice of health professionals when advising persons on driving restrictions after a transient ischaemic attack (TIA) or stroke in a tertiary hospital in New Zealand. METHODS: Health professionals working in the area of stroke care across the acute and rehabilitation services in a large tertiary hospital were invited to complete an electronic survey around knowledge of driving restrictions based on the New Zealand Transport Agency (NZTA) guidelines. Knowledge was assessed for both private and commercial vehicle use. The other information gathered included participant profession, level of seniority and experience working in stroke care, previous education around medical-related driving restrictions and how and what driving recommendations were discussed with patients. Knowledge of driving restrictions was established by the number and percentage of correct responses for each condition (single TIA, multiple TIA and stroke with full recovery) relating to the recommended restrictions in both private and commercial vehicle use. RESULTS: Forty-nine participants' surveys were analysed with representation from across all the health professions (24.5% [12/49] doctors, 38.8% [19/49] nurses and 36.7% [18/49] allied health). Only 38.8% reported having had received training around post-stroke driving restrictions. Knowledge around driving restrictions was highest for a single episode TIA for private vehicle use (73.5% [36/49]). For all other categories, fewer than 50% of participants answered correctly, with knowledge of commercial vehicle restrictions being the least accurate. CONCLUSIONS: Many health professionals have discussions with people about driving restrictions following a TIA or stroke. However, there appears to be limited knowledge of all the restrictions for each condition as they relate to either private or commercial vehicle use. Insufficient training and education for clinicians might explain this gap.

Uncovering strengths within community dwelling older adults: What does it mean for health care practice?

The aim of this paper is to present the psychological strengths we identified from interviews with community dwelling older adults. Data for this paper is drawn from participants in a community dwelling older adult study. The latter involved qualitative in-depth interviews with the participants exploring their well-being. All participants were community dwelling and living in a region in the North Island of New Zealand. Interviews took place between March 2017 to September 2017. Thirty-seven older adults between the ages of 66-99 took part in semi-structured interviews and all interviews were audio-recorded. Interviews ranged from 1 to 3 hr. Analysis was informed by the Values in Action Character strengths framework. We were able to identify strengths within the VIA conceptual framework comprising; cognitive strengths, emotional strengths, social and community strengths, protective strengths and transcendental strengths. Throughout this study we found that participants experienced difficulties in identifying and talking about their strengths. In many ways this may reflect participants' strength of humility, demonstrating modesty in talking about themselves. This study has highlighted the challenges older adults experienced in identifying their own strengths. However, the study has demonstrated how narratives can be one way of uncovering psychological strengths with older adults. In particular, these findings highlight the range of strengths, for example, bravery, gratitude, hope, humour, kindness, perseverance, spirituality, that older adults have and give a voice in highlighting these. However, more practical ways of making strength-based practices workable in daily practice, for example, in clinical assessment and health promotion programs are required.

An exploration of how community-dwelling older adults enhance their well-being.

AIM AND OBJECTIVES: To explore community-dwelling older adults approaches to enhancing their psychological well-being. BACKGROUND: Older adults who are living with long-term or chronic health conditions are particularly at risk of experiencing low psychological well-being. Little attention has been paid to preventive strategies that enhance psychological well-being and, in particular, to understanding how older adults enhance their own well-being. METHODS: Using Seligman's PERMA model of well-being (2011) as an organisational framework, this qualitative study interviewed 48 older people aged between 66 and 99 years. Of these, 17 men and 20 women participated in semi-structured interviews. Additionally, 11 women, all widows with a mean age of 81 years, participated in a focus group. The data were analysed with reference to the five aspects of PERMA (Positive emotion, Engagement, Relationships, Meaning, Accomplishment) with a focus on identifying what actions the older people were taking to enhance their well-being. Further analysis involved coding the data into processes or practices and also influencing factors. FINDINGS: Most participants used a range of strength-based strategies or practices to enhance their well-being. For a small number of participants (n = 3), these practices were supported by the presence of partners as carers. However, using PERMA as our conceptual model illustrated that despite Seligman's view that individuals can take positive action within each of the five aspects of PERMA to enhance well-being, external factors, for example economic circumstances or mobility, can influence the ability of older adults to undertake well-being practices. CONCLUSIONS: Older adults have a range of strategies or practices that they use to enhance their well-being. However, well-being is not a static concept and it is important to recognise the influence of health, social and environmental factors as enablers and enhancers of well-being. IMPLICATIONS FOR PRACTICE: Nurses can play a central role in supporting older adults who may be at risk of lower well-being. Nurses can do this by developing interventions to enhance well-being and ensuring better person-activity fit of strategies and practices. Our findings support the need for nurses to be involved in providing opportunities for older people to discuss well-being to support the development of individual, as well as community, models of well-being.

Time and change in health care.

Purpose The purpose of this paper is to explore the dimensions of temporality that are rarely considered in the literature on leading change. Design/methodology/approach The analysis is informed by Adams' (1995) social theory of time encompassing temporality, timing and tempo. This will illustrate the complexities of time as they relate to the individual, teams and organisation. Findings This paper demonstrates the multidimensional nature of time: temporality, timing and tempo, and how each of these can contribute to our understanding of the temporal nature and complexity of change within the health system. A framework to inform much-needed research in the area of time and change is presented. Practical implications Challenging assumptions that there is only one common time, that is clock time, can provide opportunities for further discussion and understanding of how various people view time and the influence this has on leading and participating in change in health care. Originality/value There is limited literature on the temporal dimensions of change at an organisational, team and individual level. The perspective offered in this paper presents the multidimensional nature of time and the influence this has on understanding the temporal nature of change and critically identifies some key areas for future research.