"Unless someone sees and hears you, how do you know you exist?" Meanings of confidential conversations - a hermeneutic study of the experiences of patients with palliative care needs.

BACKGROUND: Patients with palliative care needs live with the reality of limited time due to illness or age, eliciting emotional and existential responses. A failure to address their existential needs can lead to significant suffering. A person-centred approach is paramount to effectively address these needs, emphasising holistic care and effective communication. Although existing communication models focus on predefined frameworks, a need exists to explore more spontaneous and confidential conversations between patients and nurses. Confidential conversations have the potential to build therapeutic relationships and provide vital emotional support, highlighting the need for further research and integration into palliative care practice. This study aims to more deeply understand the meaning of confidential conversations for patients with palliative care needs. METHODS: In-depth interviews were conducted with 10 patients in the context of specialised palliative care. A hermeneutic analysis was used to gain a deeper understanding of the meanings of the conversations. RESULTS: The patients had varying experiences and wishes concerning confidential conversations. They strived for self-determination in finding confidants, seeking trust and comfort in their interactions with nurses. Trust was crucial for creating a safe space where patients could express themselves authentically. In shared belonging, confidential conversations with a nurse provided validation and relief from life's challenges. Experiences of feeling unheard or rejected by a nurse could intensify loneliness, prompting individuals to withdraw and remain silent. Regardless of the motives behind their choices, it was crucial that patients felt respect and validation in their decisions. Their autonomy could thus be recognised, and they felt empowered to make decisions based on their unique preferences. CONCLUSIONS: Patients value trust and understanding, particularly in confidential conversations with nurses, which offer solace, validation and empowerment. However, indifference can increase patients' suffering, fostering self-doubt and reluctance to engage further. To address this, health care can prioritise empathic communication skills, offer ongoing support to nurses, and promote continuity in care through investment in training and resources. Additionally, adopting a person-centred approach in confidential conversations is crucial, considering patients' varying preferences.

"Daring to deal with the difficult and unexpected" registered nurses' confidential conversations with patients with palliative care needs: a qualitative interview study.

BACKGROUND: In palliative care, registered nurses provide advanced nursing care to relieve patients' symptoms and increase their quality of life based on physical, mental, social and existential dimensions. Conversations, often about existential issues, are an important part of nursing and can affect quality of life positively. Confidential conversations between patients and nurses occur naturally while other nursing activities are being performed. Despite their great importance for palliative care these are rarely described. AIM: To gain a deeper understanding of how nurses in palliative care experience and describe confidential conversations with patients. METHOD: Secondary analysis of data from 17 open-ended face-to-face interviews with registered nurses in palliative care was conducted. Qualitative content analysis using an inductive approach was used to gain a deeper understanding and analyse the latent content. RESULTS: The confidential conversation was considered an important part of palliative care and is the nurse's responsibility. This responsibility was described as complex and placed various demands on the nurses, both personal and professional. A prerequisite for the conversation was the interpersonal relationship. The conversation allowed the patient to process important matters not previously addressed or put into words. It had no predetermined content, was unplanned and entirely on the patient's terms. For nurses the conversation could be experienced both as draining and a source of power and strength. The nurses also described safeguarding the patient through the conversation. CONCLUSION: Nurses' confidential conversations with patients are essential in palliative care and must be highlighted more to increase the quality of palliative care. The confidential conversations often have an existential content and are challenging for the nurses. Therefore, nurses need time, knowledge, and supervision to increase their conversation skills.

Teaching to prepare undergraduate nursing students for palliative care: nurse educators' perspectives.

BACKGROUND: Education in palliative care for undergraduate nursing students is important for the competence of general nurses. Newly graduated nurses have reported challenges in coping with their own emotions when encountering dying persons. They express a wish for more education before they graduate, particularly in psychosocial and existential areas, such as having difficult conversations and supporting grieving persons. Despite awareness of the importance of palliative care education for nurses, there is a lack of knowledge on how to effectively convey this knowledge to students. The aim of the present study was to explore how teaching to prepare undergraduate nursing students for palliative care practice is conducted in Sweden. METHODS: Educators from 22 Bachelor of Science nursing programmes in Sweden were interviewed about how they conducted palliative care education, with a focus on teaching situations that have been successful or less successful. The interviews were transcribed and analysed using qualitative inductive content analysis. RESULTS: Educators described that they play a crucial role in preparing undergraduate nursing students to face death and dying and to care for persons at the end of life. In the main theme, "Transforming person-centred palliative care into student-centred education", educators described how they incorporated the person-centred palliative approach into their teaching. Educators used a dynamic style of teaching where they let the students' stories form the basis in a co-constructed learning process. The educators trusted the students to be active partners in their own learning but at the same time they were prepared to use their expert knowledge and guide the students when necessary. Discussion and reflection in small groups was described as being essential for the students to achieve a deeper understanding of palliative care and to process personal emotions related to encountering dying and grieving individuals. CONCLUSIONS: This study suggests that palliative care education for undergraduate nursing students benefits from teaching in smaller groups with room for discussion and reflection. Furthermore, gains are described relating to educators taking the role of facilitators rather than traditional lecturers, being flexible and ready to address students' emotions. Educators also draw on their experiences as palliative care nurses in their teaching practices.

Beyond the monitors: Anaesthesiologists' experiences of the process of extubation.

BACKGROUND: Although extubation is a high-risk phase associated with risk of severe complications for patients undergoing general anaesthesia, there is a lack of research about this phenomenon from the perspective of anaesthesiologists' experiences of the process of extubation in the anaesthesia setting. AIM: To describe Swedish anaesthesiologists' experiences of the extubation process in the anaesthesia setting. METHODS: A qualitative descriptive design study with individual semi-structured interviews was conducted in three hospitals in Sweden with a total of 17 anaesthesiologists. A qualitative manifest content analysis method was used to analyse the data. RESULTS: The anaesthesiologists' experiences were described in two categories: To assemble sensibilities, where the anaesthesiologists are receptive to inputs, create tailored plans, are guided by emotions and experiences, and sense the atmosphere in the process of extubation; and To stay focused, where they understand the importance of preparation and being prepared, and of being calm and strategic, and of needing to trust the registered nurse anaesthetist in the process of extubation. CONCLUSIONS: Decision-making regarding the process of extubation does not rely solely on monitoring signs; rather, the anaesthesiologists described how, by looking beyond the monitors and by being receptive to inputs from the patient and other professionals, their experience and intuition guides them through the process of extubation.

Teaching about death and dying-A national mixed-methods survey of palliative care education provision in Swedish undergraduate nursing programmes.

BACKGROUND: In coming decades, the number of people affected by illnesses who need palliative care will rise worldwide. Registered Nurses are in a central position in providing this care, and education is one of the necessary components for meeting coming requirements. However, there is a lack of knowledge about palliative care in undergraduate nursing education curricula, including the extent of the education provided and the related pedagogical methods. AIM: The aim was to investigate the extent, content and pedagogical methods used and to explore lecturers' experiences of being responsible for teaching and learning about palliative care for undergraduate nursing students on nursing programmes at Swedish universities. SETTING: All 24 universities responsible for providing undergraduate nursing education in Sweden participated. PARTICIPANTS: One lecturer with in-depth knowledge about palliative care or end-of-life care education participated in the quantitative (n = 24) and qualitative (n = 22) parts of the study. METHOD: A mixed-method research study with an explorative design was used. Descriptive statistics were used to analyse quantitative data, and content analysis for qualitative, with both also analysed integratively. RESULTS: Few undergraduate nursing programmes included a specific course about palliative care in their curricula, however, all universities incorporated education about palliative care in some way. Most of the palliative care education was theoretical, and lecturers used a variety of pedagogical strategies and their own professional and personal experience to support students to understand the palliative care approach. Topics such as life and death were difficult to both learn and teach about. CONCLUSIONS: There is a need for substantial education about palliative care. Lecturers strive on their own to develop students' understanding and increase the extent of palliative care education with innovative teaching strategies, but must compete with other topics. Palliative care teaching must be prioritised, not only by the universities, but also by the national authority.

Safeguarding the patient: a grounded theory study of registered nurse anesthetists' main concerns in the process of extubation in the anesthesia setting.

BACKGROUND: The process of extubation is complex as it takes place in the technical and challenging environment of the operating room. The extubation is related to complications of varying severity and a critical moment for the patient, who is in a vulnerable condition when emerging from anesthesia. Registered Nurse Anesthetists (RNAs) in Sweden have specialist training and performs extubations independently or in collaboration with an anesthesiologist. AIM: To obtain a deeper understanding of Registered Nurse Anesthetists' main concerns and how they resolve these in the process of extubation when caring for a patient during general anesthesia. PARTICIPANTS: A total of 17 RNAs, eight male and nine female, were included in the study. Twelve RNAs in the first step of data collection (I); and five RNAs the second step of data collection (II). METHOD: A classic grounded theory approach with a qualitative design was used for this study. FINDINGS: The RNAs' main concern in the process of extubation were Safeguarding the patient in a highly technological environment, which the solved by Maintaining adaptability. Facilitators as well as challenges affected how the RNAs solved their main concern and represented the categories: 'Having a back-up plan', 'Getting into the right frame of mind', 'Evaluating the patient's reactions', 'Using one's own experience', 'Dealing with uncertainty', 'Pressure from others', and 'Being interrupted'. The theory, Safeguarding the patient in the process of extubation, emerged. CONCLUSION: To be able to safeguard the patient in a highly technological environment, the RNAs must oscillate between facilitators and challenges. By maintaining adaptability, the RNAs resolved the difficulties of oscillating, indicating a need for finding a balance between maintaining attentiveness on what is important to keep the patient safe in the process of extubation and all of the disturbances present in the OR.

A third of dying patients do not have end-of-life discussions with a physician: A nationwide registry study.

OBJECTIVE: The aim of the study was to explore the proportion of adult patients and next-of-kin who had end-of-life (EOL) discussions and associated factors. METHOD: A retrospective nationwide registry study was reported with data from the Swedish Register of Palliative Care. All patients in Sweden in hospitals, nursing homes, own homes, community, and palliative care units during 2015-2017 and their next-of-kin were included. Data were reported to the register by healthcare staff, based on diseased patients' records regarding their last days of life, and were voluntary. Descriptive statistics illustrated the proportion of patients/next-of-kin who had EOL discussions and logistic regressions were used to examine associated factors. RESULTS: About half of the patients (46%) did have an EOL discussion, but a third (32%) did not. Associated factors of those who did not have an EOL discussion were dementia (48.5%) or stroke (47.5%), older age (38.4%), being female (33.6%), being cared for in a nursing home (41.3%), or hospital (40.3%), having lost decision-making ability months before death (58.9%), and not having a documented decision to shift to EOL care (82.7%). Younger patients diagnosed with cancer and cared for at a palliative unit were more likely to have EOL discussions. The regression analysis showed similar results for next-of-kin. SIGNIFICANCE OF RESULTS: The result shows that not all patients with palliative care needs have equal access to EOL discussions, despite efforts at a national level and the recognized benefits of timely communication about the EOL care. Further efforts must be made to achieve EOL discussions for all patients.

The Art Is to Extubate, Not to Intubate-Swedish Registered Nurse Anesthetists' Experiences of the Process of Extubation After General Anesthesia.

PURPOSE: To describe Registered Nurse Anesthetists' (RNA's) experiences of the process of extubation of the endotracheal tube in patients undergoing general anesthesia. DESIGN: A descriptive qualitative design. METHODS: This study was conducted in two hospitals with 20 RNAs in total. Data were generated from focus group interviews. Content analysis was used to analyze data. FINDINGS: The RNAs' experiences were described within four categories and eight subcategories. The category To be a step ahead includes assessment and preparation, and To be on my toes, their ability to recognize patterns and build a connection. To use situation awareness relates to their use of experience and feelings, and To be alone in a critical moment, to feeling alone in the team and protecting the patient. CONCLUSIONS: The RNAs make decisions when to extubate by combining theoretical knowledge, clinical experience, and intuition with the uniqueness of each patient.

Undergraduate nursing students' transformational learning during clinical training.

BACKGROUND: Undergraduate nursing students encounter patients at the end of life during their clinical training. They need to confront dying and death under supportive circumstances in order to be prepared for similar situations in their future career. AIM: To explore undergraduate nursing students' descriptions of caring situations with patients at the end of life during supervised clinical training. METHODS: A qualitative study using the critical incident technique was chosen. A total of 85 students wrote a short text about their experiences of caring for patients at the end of life during their clinical training. These critical incident reports were then analysed using deductive and inductive content analysis. FINDINGS: The theme 'students' transformational learning towards becoming a professional nurse during clinical training' summarises how students relate to patients and relatives, interpret the transition from life to death, feel when caring for a dead body and learn end-of-life caring actions from their supervisors. IMPLICATIONS: As a preparation for their future profession, students undergoing clinical training need to confront death and dying while supported by trained supervisors and must learn how to communicate about end-of-life issues and cope with emotional stress and grief.

Clinical intuition in the nursing process and decision-making-A mixed-studies review.

AIMS AND OBJECTIVES: To review what is characteristic of registered nurses' intuition in clinical settings, in relationships and in the nursing process. BACKGROUND: Intuition is a controversial concept and nurses believe that there are difficulties in how they should explain their nursing actions or decisions based on intuition. Much of the evidence from the body of research indicates that nurses value their intuition in a variety of clinical settings. More information on how nurses integrate intuition as a core element in daily clinical work would contribute to an improved understanding on how they go about this. Intuition deserves a place in evidence-based activities, where intuition is an important component associated with the nursing process. DESIGN: An integrative review strengthened with a mixed-studies review. METHODS: Literature searches were conducted in the databases CINAHL, PubMed and PsycINFO, and literature published 1985-2016 were included. The findings in the studies were analysed with content analysis, and the synthesis process entailed a reasoning between the authors. RESULTS: After a quality assessment, 16 studies were included. The analysis and synthesis resulted in three categories. The characteristics of intuition in the nurse's daily clinical activities include application, assertiveness and experiences; in the relationships with patients' intuition include unique connections, mental and bodily responses, and personal qualities; and in the nursing process include support and guidance, component and clues in decision-making, and validating decisions. CONCLUSION: Intuition is more than simply a "gut feeling," and it is a process based on knowledge and care experience and has a place beside research-based evidence. Nurses integrate both analysis and synthesis of intuition alongside objective data when making decisions. They should rely on their intuition and use this knowledge in clinical practice as a support in decision-making, which increases the quality and safety of patient care. RELEVANCE TO CLINICAL PRACTICE: We find that intuition plays a key role in more or less all of the steps in the nursing process as a base for decision-making that supports safe patient care, and is a validated component of nursing clinical care expertise.

Healthcare professionals' documentation in nursing homes when caring for patients with dementia in end of life - a retrospective records review.

AIMS AND OBJECTIVES: To investigate how end-of-life care was described by healthcare professionals in records of deceased persons affected by dementia who had lived in Swedish nursing homes. BACKGROUND: In the final stage of dementia disease, the persons are often cared for at nursing homes and they often die there. The research concurs that a palliative approach to end-of-life care is essential but there are still some limitations regarding research about what constitutes the end-of-life care provided to persons affected by dementia in Sweden. DESIGN: Descriptive qualitative method with a retrospective approach. METHOD: Nursing records (n = 50) and medical records (n = 50) were retrospectively reviewed in two nursing homes. The analysis was conducted using deductive and inductive content analysis. Three phases of The Liverpool Care Pathway; Initial assessment, Continuous assessment and Follow-up, were used deductively to first sort the text in the records, then the text in each phase was further analysed with inductive content analysis. Four categories and 11 subcategories described the content in the records. RESULTS: The end-of-life care was described in the healthcare records based on such categories as decision-making, participation and communication, assessment and prevention of symptom and following up after the residents had died. CONCLUSION: Paticularly, physical symptoms were documented and, to a lesser degree, psychological or existential/spiritual needs. RELEVANCE TO CLINICAL PRACTICE: Healthcare professionals must have a holistic view of the person affected by dementia during the end-of-life care and, according to this study, more focus must be placed on their psychosocial and existential needs in the documentation of end-of-life care.

Factors influencing attitude toward care of dying patients in first-year nursing students.

AIM: To describe Swedish first-year undergraduate nursing students' attitudes toward care of dying patients. Possible influences such as age, earlier care experiences, care education, experiences of meeting dying patients and place of birth were investigated. METHOD: The Frommelt Attitude Toward Care of the Dying Scale (FATCOD) was used in six universities. Descriptive statistics and regression analysis were used. RESULTS: Some 371 students (67.3%) reported overall positive attitude toward caring for dying patients (total mean FATCOD 119.5, SD 10.6) early in their first semester. Older students, students with both earlier care experience and earlier education, those with experience of meeting a dying person, and students born in Sweden reported the highest scores, a more positive attitude. CONCLUSION: Age, earlier care experience and education, experiences of meeting a dying person and place of birth seems to affect students' attitudes toward care of the dying and need to be considered among nursing educators.

Patients' perspectives on information from physicians during palliative chemotherapy: A qualitative study.

OBJECTIVE: During the course of their disease, patients with cancer receiving palliative chemotherapy receive extensive amounts of information from physicians. The objective of our study was to describe patients' perspectives on the information they received from physicians during palliative chemotherapy with regard to their cancer diagnosis, treatments, prognosis, and future planning. METHOD: A total of 15 semistructured face-to-face interviews with patients who had incurable cancer were conducted, transcribed verbatim, and analyzed with qualitative content analysis. RESULTS: Three categories were defined during the analytical process: "having a chronic disease," "depending on chemotherapy," and "living with an unpredictable future." SIGNIFICANCE OF RESULTS: Our study demonstrated that patients undergoing palliative chemotherapy perceived that their disease was incurable and chronic, that they were dependent on chemotherapy, and that their future was uncertain. Compared with other studies, the patients in our study seemed to be more aware of their prognosis and the goals of care.

The need for palliative care education, support, and reflection among rural nurses and other staff: A quantitative study.

OBJECTIVE: Many people now die in community care, and, considering the aging population, all healthcare staff members must be prepared to provide palliative care. Our objectives were to describe the total staff working in different care organizations in a rural community in Sweden and to explore palliative care competence, to describe educational gaps and the need for support and reflection, and to determine whether there are differences in care organizations, professions, age, and gender. METHOD: A 4-section 20-item questionnaire was distributed to 1686 staff (65% response rate): in nursing homes (n = 395), home care (n = 240), and group residential settings (n = 365). Registered nurses (n = 70), assistant nurses (n = 916), managers (n = 43), and paramedics (n = 33) participated. Descriptive and correlational statistics were employed. RESULTS: Significant differences were found, and 40% (53% among men) lacked palliative care education, Fewer than 50% lacked education in the spiritual/existential areas, and 75% of those aged 20-66 (75% women, 55% men) needed further education. More women than men and staff aged 50-59 had an increased need to reflect. SIGNIFICANCE OF RESULTS: Our study may provide guidance for managers in rural communities when planning educational interventions in palliative care for healthcare staff and may support direct education with content for specific professions.

Development of an existential support training program for healthcare professionals.

OBJECTIVE: Our aim was to describe the developmental process of a training program for nurses to communicate existential issues with severely ill patients. METHOD: The Medical Research Council (MRC) framework for the development and evaluation of complex interventions was used to develop a training program for nurses to communicate about existential issues with their patients. The steps in the framework were employed to describe the development of the training intervention, and the development, feasibility and piloting, evaluation, and implementation phases. The development and feasibility phases are described in the Methods section. The evaluation and implementation phases are described in the Results section. RESULTS: In the evaluation phase, the effectiveness of the intervention was shown as nurses' confidence in communication increased after training. The understanding of the change process was considered to be that the nurses could describe their way of communicating in terms of prerequisites, process, and content. Some efforts have been made to implement the training intervention, but these require further elaboration. SIGNIFICANCE OF RESULTS: Existential and spiritual issues are very important to severely ill patients, and healthcare professionals need to be attentive to such questions. It is important that professionals be properly prepared when patients need this communication. An evidence-based training intervention could provide such preparation. Healthcare staff were able to identify situations where existential issues were apparent, and they reported that their confidence in communication about existential issues increased after attending a short-term training program that included reflection. In order to design a program that should be permanently implemented, more knowledge is needed of patients' perceptions of the quality of the healthcare staff's existential support.

Communication about existential issues with patients close to death--nurses' reflections on content, process and meaning.

OBJECTIVE: Encountering dying patients with implicit existential questions requires the nurses to have positive and comfortable attitude to talking about existential issues. This paper describes the nurses' reflections on existential issues in their communication with patients close to death. METHODS: Nurses (n = 98) were recruited from a hospital, hospices and homecare teams. Each nurse participated in five group reflection sessions that were recorded, transcribed and analysed using qualitative content analysis. RESULTS: Three domains and nine themes emerged. The content domain of the existential conversation covered living, dying and relationships. The process domain dealt with using conversation techniques to open up conversations, being present and confirming. The third domain was about the meaning of existential conversation for nurses. The group reflections revealed a distinct awareness of the value of sensitivity and supportive conversations. CONCLUSION: This study supports the assertion that experience of talking about existential issues and supporting environment make nurses comfortable when counselling patients close to death. It was obvious from this study that having the courage to be present and confirming, having time and not trying to 'solve' every existential problem were the most important factors in conversations with the patients close to death.

The existential life situations of spouses of persons with dementia before and after relocating to a nursing home.

OBJECTIVES: The aim was to describe the existential life situations of spouses who care for persons with dementia, before and after relocation to nursing homes. METHOD: This was a qualitative study among 11 spouses of persons with dementia, recruited via purposeful sampling. Data were collected through interviews and analysed with interpretive content analysis. RESULTS: Before the relocation to nursing homes, the spouses' existential life situations were characterized by feelings of shame and guilt, being isolated in the home. Spouses were also exposed to psychological threats, physical violence, and had feelings of placing one's own needs last. After the relocation, spouses described feelings of guilt and freedom, living with grief and thoughts of death, feelings of loneliness in the spousal relationship, and striving for acceptance despite a lack of completion. CONCLUSION: The existential life situation of spouses of persons with dementia is about being in limit situations which changes when the ill person relocates to a nursing home. This is important knowledge for health care staff to bear in mind at nursing homes when encountering spouses.

When a child dies: parents' experiences of palliative care-an integrative literature review.

The aim of this integrative review was to increase knowledge about parents' experiences of palliative care when their child is dying or has died due to illness using Whittemore and Knafl (2005) analysis process. Computerized databases were used to search the literature. Nine papers met the inclusion criteria. The analysis resulted in five categories: genuine communication, sincere relationships, respect as an expert, and alleviation of suffering and need of support, including 15 subcategories. Health professionals need education to provide high-quality pediatric palliative care. They especially need training concerning existential issues, and further studies need to be performed.

Reflections of older people living in nursing homes.

AIM: To explore experiences of ageing in older people living in nursing homes, based on the gerotranscendence theory. METHOD: Interviews were held with 14 people aged between 80 and 96 years. The results were analysed using content analysis. FINDINGS: The findings were divided into three categories: the self, the cosmic dimension, and social and personal relationships. These three categories were underpinned by eight subcategories. Most participants described improved knowledge about themselves, decreased concern about body and appearance, acceptance and appreciation of life, and less regard for social norms. A fewer participants described a greater affinity with past generations, or thought that the borders between past and present had become blurred. CONCLUSION: This study provides a better understanding of how people experience old age. It also indicates how healthcare professionals could apply the gerotranscendence theory of ageing as a conversation model to enable care to be adjusted according to older people's wishes.