A systematic review and meta-synthesis of qualitative studies that investigate the emotional experiences of staff working in homeless settings.

Homelessness is a pervasive issue in society, and government policies have highlighted the need to focus on the experience of front-line staff in homelessness settings. The aim of this meta-synthesis was to draw together the available research to further understanding of the experiences of staff working with homeless people. A systematic search was conducted across four electronic databases (ASSIA, PsycInfo, Sociological Abstracts and Web of Science) from the date of their inception. Qualitative research exploring the emotional experiences of staff working in homeless settings was identified. Identified studies were subject to quality assessment, and the data were synthesised using meta-ethnography. Ten studies were included in the synthesis following screening of 228 titles, 92 abstracts and 33 full texts. The concepts that were obtained from the analysis were building quality relationships, negotiating boundaries, carrying the emotional burden (self and others), accessing care and support (self-care and from others), individual advancement, advocating and contextual helplessness. An overarching theoretical construction of the internal experiences of support staff in managing the demands of the role along with their own needs was developed. This theory may provide the basis for testable hypotheses in future research and inform the development of support and training opportunities for staff working within homelessness settings.

Training and supportive programs for palliative care volunteers in community settings.

BACKGROUND: Palliative care is specialised health care to support people living with a terminal illness and their families. The involvement of volunteers can extend the range of activities offered by palliative care services, particularly for those living in the community. Activities undertaken by palliative care volunteers vary considerably but can be practical, social or emotional in nature. The types of training and support provided to these volunteers are likely to affect the volunteers' effectiveness in their role and influence the quality of care provided to palliative care clients and their families. Training and support can also have considerable resource implications for palliative care organisations, which makes it important to know how to provide this training and support as effectively as possible. OBJECTIVES: To assess the effects of training and support strategies for palliative care volunteers on palliative care clients and their families, volunteers and service quality. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, 28 April 2014); MEDLINE (1946 to 28 April 2014); EMBASE (1988 to 28 April 2014); PsycINFO (1806 to 28 April 2014); CINAHL (EbscoHOST) (1981 to 28 April 2014); ProQuest Dissertations and Theses (1861 to 28 April 2014). We also searched the Database of Abstracts of Reviews of Effects (DARE, The Cochrane Library); reference lists of relevant studies; and conducted an extensive search for evaluations published in government reports and other grey literature including the CareSearch database (www.caresearch.com.au (September 2004 to February 2012) and websites of relevant organisations, for unpublished and ongoing studies. SELECTION CRITERIA: Randomised controlled trials (RCTs), quasi-randomised controlled trials, controlled before-and-after (CBA) studies and interrupted time series (ITS) studies of all formal training and support programs for palliative care volunteers. Programs or strategies in included studies were classified according to any stated or implied purpose: that is, whether they intended to build skills for the volunteer's role, to enhance their coping, or to maintain service standards. DATA COLLECTION AND ANALYSIS: Two review authors screened 2614 citations identified through the electronic searches after duplicates were removed. The search of grey literature through websites yielded no additional titles. We identified 28 potentially relevant titles but found no studies eligible for inclusion. MAIN RESULTS: We did not find any studies that assessed the effects of training and support strategies for palliative care volunteers that meet our inclusion criteria. The excluded studies suggest that trials in this area are possible. AUTHORS' CONCLUSIONS: The use of palliative care volunteers is likely to continue, but there is an absence of evidence to show how best to train or support them whilst maintaining standards of care for palliative care patients and their families.

Emergency and palliative care nurses' levels of anxiety about death and coping with death: a questionnaire survey.

BACKGROUND: Caring for dying patients and their families presents many challenges, and may be negatively affected by nurses' Fear of Death. This study investigates attitudes of emergency and palliative care nurses towards death and dying. METHODS: A mixed methods design including questionnaire and interview, was utilised. This paper reports questionnaire results from the Death Attitude Profile-Revised Scale and coping skills. RESULTS: Twenty-eight emergency nurses and 28 palliative care nurses from two health services participated. Nurses held low to moderate Fear of Death (44%), Death Avoidance (34%), Escape Acceptance (47%) and Approach Acceptance (59%). Emergency nurses reported higher death avoidance and, significantly lower coping skills than palliative care nurses. Both reported high acceptance of the reality of death (Neutral Acceptance 82%), and indicated they coped better with a patient who was dying than with, the patient's family. CONCLUSIONS: Nurses generally held positive attitudes towards death and dying. Participants could cope with caring for dying patients, but were significantly less comfortable coping with patients' family members. Nurses should be aware of the impact their attitude towards death may have on providing supportive nursing care for the dying.

Care providers' views and experiences of postnatal care in private hospitals in Victoria, Australia.

OBJECTIVE: in Australia, as in other developed countries, women have consistently reported lower levels of satisfaction with postnatal care compared with antenatal and intrapartum care. However, in Victoria Australia, women who receive private hospital postnatal care have rated their care more favourably than women who received public hospital care. This study aimed to gain a further understanding of this by exploring care providers' views and experiences of postnatal care in private hospitals. DESIGN: qualitative design using semi-structured interviews and thematic analysis. SETTING: private maternity hospitals in Victoria, Australia. PARTICIPANTS: eleven health-care providers from three metropolitan and one regional private hospital including eight midwives (two maternity unit managers and six clinical midwives) and three obstetricians. FINDINGS: two global themes were identified: 'Constrained Care' and 'Consumer Care'. 'Constrained care' demonstrates the complexity of the provision of postnatal care and encompasses midwives' feelings of frustration with the provision of postnatal care in a busy environment complicated by staffing difficulties, a lack of continuity and the impact of key players in postnatal care (including visitors, management and obstetricians). 'Consumer care' describes care providers' views that women often approach private postnatal care as a consumer, which can impact on their expectations and satisfaction with postnatal care. Despite these challenges, care providers, particularly midwives, highly valued (and generally enjoyed working in) postnatal care. KEY CONCLUSIONS: this study, along with other Australian and international studies, has identified that hospital postnatal care is complex and characterised by multiple barriers which impact on the provision of quality postnatal care. Further research is needed to evaluate routine postnatal practices and continuity of care within the postnatal period. In-depth qualitative studies investigating women's expectations and experiences of postnatal care in both the public and private sector are also needed.

A case study approach to investigating end-of-life decision making in an acute health service.

AIM: To identify end-of-life (EOL) decision making processes for patients with non-cancer illnesses in a major metropolitan hospital. METHODS: A retrospective review using a case study framework of 47 randomly selected patient records over a 6-month period explored issues in EOL care planning. RESULTS: Reviewed charts represented 53% of total deaths in the study period. All patients (aged 66-99) had co-morbid conditions. In 64%, the first record of EOL discussions occurred in the last 24h of life. Four case groups were identified, ranging from a clear plan developed with patient/family involvement and fully implemented, to no plan with minimal patient/family involvement in decision making. Factors related to clearer EOL care planning according to expressed patient wishes included multiple previous admissions, shorter hospitalisations at EOL, living with a relative and involvement of family in decisions about care. CONCLUSION: This study has shown that the development and effective implementation of EOL plans is associated with the active involvement of both family members and health professionals. It also draws attention to the risks of delaying EOL discussions until late in the illness trajectory or later in life as well as pointing to challenges in acting on EOL developed outside the hospital environment.

The environment of inpatient healthcare delivery and its influence on the outcome of care.

AIM: This paper addresses issues arising in the literature regarding the environmental design of inpatient healthcare settings and their impact on care. BACKGROUND: Environmental design in healthcare settings is an important feature of the holistic delivery of healthcare. The environmental influence of the delivery of care is manifested by such things as lighting, proximity to bedside, technology, family involvement, and space. The need to respond rapidly in places such as emergency and intensive care can override space needs for family support. In some settings with aging buildings, the available space is no longer appropriate to the needs-for example, the need for privacy in emergency departments. Many aspects of care have changed over the last three decades and the environment of care appears not to have been adapted to contemporary healthcare requirements nor involved consumers in ascertaining environmental requirements. The issues found in the literature are addressed under five themes: the design of physical space, family needs, privacy considerations, the impact of technology, and patient safety. CONCLUSION: There is a need for greater input into the design of healthcare spaces from those who use them, to incorporate dignified and expedient care delivery in the care of the person and to meet the needs of family.Preferred Citation: O'Connor, M., O'Brien, A., Bloomer, M., Morphett, J., Peters, L., Hall, H., … Munro, I. (2012). The environment of inpatient healthcare delivery and its influence on the outcome of care. Health Environments Research & Design Journal, 6(1), 105-117.

Is work stress in palliative care nurses a cause for concern? A literature review.

UNLABELLED: Palliative care nurses are at risk of work stress because their role involves exposure to frequent deaths and family grieving. Little is known about their degree of stress or whether they suffer stress or burnout more than nurses in other disciplines. AIM: The aim of this paper is to critically examine the current literature concerning stress and burnout in palliative care nurses. RESULTS: Sixteen papers were included in the review. Although work demands were a common cause of stress in the studies reported, there was no strong evidence that palliative care or hospice nurses experienced higher levels of stress than nurses in other disciplines. Common causes of stress were the work environment, role conflict, and issues with patients and their families. Constructive coping styles appeared to help nurses to manage stress. CONCLUSION: Managers have a key role in providing education and training for palliative care nurses to support their personal development and to help reduce vulnerability to and the impact of stress in the workplace.

Nurse-family interaction in Malaysian palliative care settings: a focused literature review.

BACKGROUND: Palliative care in Malaysia developed in the 1990s to improve the quality of life of people with advanced cancer. Like many other countries, Malaysia faces its own challenges in providing palliative care to patients and their families. In Malaysian culture, families play a significant part in providing care to the dying. Connecting with families in patient care is therefore important. This paper reports a focused literature review evaluating studies on the care of the families of terminally ill people in palliative care environments in Malaysia. METHOD: The search engines CINAHL, Medline, PsycINFO, and Google Scholar were searched for literature published from January 2000 to April 2010 relating to family care in palliative care environments. Due to a paucity of research on family care in Malaysia, the search was broadened to include relevant studies on family care internationally. RESULTS: Four themes were identified: delivering palliative care in Malaysia, communicating with families, crossing cultural boundaries, and the caring experience of nurses. CONCLUSION: The studies indicate the importance of the nurse-family interaction in providing optimal and culturally appropriate palliative care. This paper emphasizes the need for research into the nurse's role in family care and for developing a theory appropriate to the Malaysian culture and other countries with cultural diversity.

A statewide review of postnatal care in private hospitals in Victoria, Australia.

BACKGROUND: Concerns have been raised in Australia and internationally regarding the quality and effectiveness of hospital postnatal care, although Australian women receiving postnatal care in the private maternity sector rate their satisfaction with care more highly than women receiving public maternity care. In Victoria, Australia, two-thirds of women receive their maternity care in the public sector and the remainder in private health care sector. A statewide review of public hospital postnatal care in Victoria from the perspective of care providers found many barriers to care provision including the busyness of postnatal wards, inadequate staffing and priority being given to other episodes of care; however the study did not include private hospitals. The aim of this study was replicate the review in the private sector, to explore the structure and organisation of postnatal care in private hospitals and identify those aspects of care potentially impacting on women's experiences and maternal and infant care. This provides a more complete overview of the organisational structures and processes in postnatal care in all Victorian hospitals from the perspective of care providers. METHODS: A mixed method design was used. A structured postal survey was sent to all Victorian private hospitals (n = 19) and key informant interviews were undertaken with selected clinical midwives, maternity unit managers and obstetricians (n = 11). Survey data were analysed using descriptive statistics and interview data analysed thematically. RESULTS: Private hospital care providers report that postnatal care is provided in very busy environments, and that meeting the aims of postnatal care (breastfeeding support, education of parents and facilitating rest and recovery for women following birth) was difficult in the context of increased acuity of postnatal care; prioritising of other areas over postnatal care; high midwife-to-woman ratios; and the number and frequency of visitors. These findings were similar to the public review. Organisational differences in postnatal care were found between the two sectors: private hospitals are more likely to have a separate postnatal care unit with single rooms and can accommodate partners' over-night; very few have a policy of infant rooming-in; and most have well-baby nurseries. Private hospitals are also more likely to employ staff other than midwives, have fewer core postnatal staff and have a greater dependence on casual and bank staff to provide postnatal care. CONCLUSIONS: There are similarities and differences in the organisation and provision of private postnatal care compared to postnatal care in public hospitals. Key differences between the two sectors relate to the organisational and aesthetic aspects of service provision rather than the delivery of postnatal care. The key messages emerging from both reviews is the need to review and monitor the adequacy of staffing levels and to develop alternative approaches to postnatal care to improve this episode of care for women and care providers alike. We also recommend further research to provide a greater evidence-base for postnatal care provision.

Palliative care nurse consultants in Melbourne: a snapshot of their clinical role.

AIM: The current role of the palliative care nurse consultant (PCNC) is as diverse as the organisations in which such nurses work. This study reports on Phase 2 of a larger study in Melbourne, Australia, which focused particularly on describing some of the clinical aspects of the work of the PCNC in the acute hospital setting. DESIGN: A cross-sectional survey was used to describe the selected clinical activities of the PCNC.A data collection sheet was developed to gather information about their work. SAMPLE AND SETTING: 21 PCNCs participated in the study and data were collected for 282 patients within 12 acute hospitals in Melbourne. METHODS: PCNCs recorded selected information about their clinical work for a two-week period. Descriptive analyses were carried out to calculate frequency distributions and mean scores. FINDINGS: In 73% of referrals, the PCNC was the first contact the patient had with any palliative care health professional; patients with a malignant diagnosis constituted the main workload of the PCNC; the highest number of interventions was recorded for the symptom management/psychosocial care category; and the time from acute hospital admission to PCNC consult referral was 6.57 days. CONCLUSIONS: This study has demonstrated that the work of PCNCs is complex and diverse. This research forms the basis for further study into the role of the PCNC.

Quality of life of cancer patients receiving inpatient and home-based palliative care.

AIMS: This paper reports a comparative study of the symptom experience, physical and psychological health, perceived control of the effects of cancer and quality of life of terminally ill cancer patients receiving inpatient and home-based palliative care, and the factors that predict quality of life. BACKGROUND: Quality of life is a major goal in the care of patients with terminal cancer. In addition to symptom management, psychological care and provision of support, being cared for at home is considered an important determinant of patient well-being. A more comprehensive understanding of the impact of cancer on patients and their families will inform the delivery of palliative care services. METHODS: Fifty-eight patients with terminal cancer (32 inpatients, 26 home-based) were recruited from major palliative care centres in Australia in 1999. A structured questionnaire designed to obtain sociodemographic information, medical details and standard measures of symptoms, physical and psychological health, personal control and quality of life was administered by personal interview. RESULTS: The two groups were similar on most demographic measures, although more home-care patients were married, of Australian descent and had private health insurance cover. The most prevalent symptoms reported were weakness, fatigue, sleeping during the day and pain. Patients receiving home-based services had statistically significantly less symptom severity and distress, lower depression scores, and better physical health and quality of life than those receiving inpatient care. Home-care patients also reported statistically significantly more control over the effects of their illness, medical care and treatment received, and the course of the disease. Multiple regression analyses showed that better global physical health, greater control over the effects of cancer and lower depression scores were statistically significant predictors of higher quality of life. CONCLUSIONS: The main issues arising from the findings for nurses are the early detection and management of both physical and psychological symptoms, particularly fatigue, pain, anxiety and depression, and the need to use strategies that will empower patients to have a greater sense of control over their illness and treatment. Research is needed to identify other factors that may impact on quality of life, and to establish the extent to which inpatient and home-based care meets the needs of both the patient with terminal cancer and their family.

Palliative care work, between death and discharge.

This paper discusses a small study that was undertaken in a palliative care unit (PCU) to demonstrate reasons for the lengthy patient turnover time after the death of a patient. The study arose from a managerial challenge about the PCU's efficiency in comparison to other settings of care. While palliative care services in Australia are loosely funded on a per diem rate, casemix funding models for inpatient services in other settings reward efficiency in terms of length of stay (1). The aim of the study was to undertake a post-death survey, from the nursing perspective, of activities and the time required to deliver follow-up care, as required, to the deceased patient and his/her family. Details of the post-death episode for all patients who died in the PCU over two time periods were collected using a newly designed tool. This paper does not argue for the incorporation of post-death nursing work as a measure of efficiency or quality; rather, it is a demonstration of the type of work and the time involved in carrying out post-death work. This nursing work is an essential but hidden and generally unacknowledged element of palliative care and, not surprisingly, there is a dearth of literature describing the role of the nurse in providing care of the family and others after the patient has died. This project has provided important information about the factors that protract after-death care, and gives some insight into the role of the nurse after a death occurs in a PCU.