"I'm going to push this door open. You can close it": A qualitative study of the brokering work of oncology clinic nurses in introducing early palliative care.

BACKGROUND: Early palliative care improves quality of life during life-prolonging treatment for patients with cancer, but the role of nurses in facilitating the early involvement of palliative care is unclear. AIM: To conceptualize the psychosocial processes involved in the introduction and provision of palliative care by oncology nurses. DESIGN: A constructivist qualitative grounded theory study was conducted. SETTING/PARTICIPANTS: A total of 20 nurses (6 staff nurses, 10 nurse practitioners, and 4 advanced practice nurses) completed semi-structured interviews. Participants were from multiple ambulatory care oncology clinics (i.e. breast, pancreatic, hematology) in a comprehensive cancer center. RESULTS: The core category, brokering palliative care, represented the overarching concept of the study that linked other subcategories. The other subcategories were as follows: opening the door-creating the possibility of discussing early palliative care at a time when patients show signs of being receptive to this discussion; building trust-establishing relationships with patients as a starting point for open discussions about palliative care; tackling misconceptions-addressing patients' assumptions about palliative care as signifying death; and advocating with oncologists-seeding the process of referral by bringing patients' concerns forward. CONCLUSION: Oncology nurses play a central role in "brokering" the introduction of early palliative care; this process is supported by their relational proximity to patients and their location "in between" the patient and the oncologist. Training all nurses in palliative care and empowering them to have proactive discussions in a collaborative practice context would allow greater access to early palliative care.

Availability of services in Ontario hospices and hospitals providing inpatient palliative care.

PURPOSE: Most Canadians die in inpatient settings. Our aim was to determine the availability of medical services, programs, and care for common palliative procedures, in hospices, palliative care units (PCUs), and hospital medical wards (MWs) providing inpatient palliative care in Ontario, Canada. METHODS: We identified facilities providing inpatient palliative care using the Ontario Hospital Association (OHA) and Hospice Association of Ontario (HAO) websites. An electronic survey was sent to the person responsible for palliative care at each facility. We compared services available among the three types of units, using Fisher's exact and Kruskal-Wallis tests. RESULTS: Of 128 surveys sent, 102 (80%) were completed and returned, from 58 MWs, 31 PCUs, and 13 hospices. MWs were the most common location of palliative care overall, particularly in rural areas. PCUs were most likely to provide care for common procedures (e.g., tracheostomy, nephrostomy; p<0.01); methadone for pain management (p<0.0001); and palliative radiation (p<0.01). MWs were most likely to offer intravenous chemotherapy and antibiotics (p<0.01). Transfusions were available in most PCUs and MWs, but only in one hospice (p<0.0001). Hospices were most likely to provide complementary therapies. Lack of financial support and human resources were the most frequent perceived barriers to providing quality palliative care. CONCLUSIONS: There is considerable variability of available services depending on the setting where inpatient palliative care is provided. Further financial support and resources are required to ensure consistent high quality of care in both urban and rural areas.