Psychosocial burdens in palliative care - a longitudinal cohort study in nursing homes and impacts of the COVID-19 pandemic.

BACKGROUND: In Germany, palliative care in nursing homes is becoming increasingly important. Simultaneously, nursing homes are particularly affected by the COVID-19 pandemic due to their vulnerable residents leading to increased burdens for nursing staff. Although a separate unit for palliative care may not be present in nursing homes as it is in, e.g., hospitals, palliative care occupies a large portion of the workday in nursing homes. As no study addressing this topic could be found, this study focused on the research questions of how the psychosocial burdens faced by nursing staff in palliative care have been affected by the COVID-19 pandemic and how those burdens differ from the psychosocial burdens encountered in general care. METHODS: Basen on a longitudinal cohort study design, a total of 113 nurses, nursing assistants and caregivers drawn from two nursing homes in North Rhine-Westphalia, Germany, were surveyed pre-pandemic in 2019 and during the pandemic in 2022 using the Copenhagen Psychosocial Questionnaire (COPSOQ) III. Data were examined descriptively following the standardised COPSOQ procedure. Additionally, chi-squared test was conducted to investigate the homogeneity between the groups. Mean differences (MD) were provided and Cohen's d was calculated to evaluate relevant differences in psychosocial burdens between 2019 and 2022. In a second step, t-tests were performed to test statistical significance. RESULTS: Relevant positive changes could be identified in 'Quantitative demands' (d = 0.321; MD = 5.9), 'Influence at work' (d = 0.244; MD = 5.4), 'Job insecurity' (d = 0.321; MD = 6.5), 'Insecurity over working conditions' (d = 0.296; MD = 6.8), 'Burnout symptoms related to residents' (d = 0.201; MD = 3.8), 'Degrees of freedom' (d = 0.455; MD = 9.6) and 'Presenteeism' (d = 0.425; MD = 11.8). Relevant negative changes were found in 'Dissolution' (d = 0.217; MD = 5.4; i.e., setting boundaries between work and private life), 'Role conflicts' (d = 0.282; MD = 5.5), 'Role clarity' (d = 0.251; MD = 3.3) and 'Burnout symptoms related to relatives' (d = 0.318; MD = 6.0). Relevant changes that were statistically significant according to the t-test could be identified in 'Degrees of freedom' (t-value=-2.40; p = 0.018) and 'Presenteeism' (t-value = 2.26; p = 0.026). Responses to questions concerning nursing homes' handling of the COVID-19 pandemic exhibited a mean score of 68.2 for 'Organisation/communication' and a mean score of 78.1 concerning 'Operational measures and overall assessment' during the COVID-19 pandemic. CONCLUSIONS: Besides negative changes during the COVID-19 pandemic, some categories showed more positive results. The burdens of palliative care in nursing homes may be perceived differently than those of general care in nursing homes. Furthermore, the results indicate that perceptions of challenges in palliative care in nursing homes during the pandemic seem to be highly dependent on organisational working conditions and support that can strengthen the individual resources and resilience of the staff.

Effects of the COVID-19 pandemic on hospice and palliative care in nursing homes-A qualitative study from a multiperspective view.

In Germany, nursing homes are characterised by challenging conditions for adequately supporting residents at their end of life, which have even amplified due to the COVID-19 pandemic. This article therefore analyses how hospice and palliative care in nursing homes has changed due to the COVID-19 pandemic and how the pandemic has affected residents, relatives and employees. Semi-structured interviews with employees, residents and relatives were conducted before and during the COVID-19 pandemic in two nursing homes in North Rhine-Westphalia, Germany. In a pre-post comparison, data were qualitatively evaluated using content analysis according to Mayring. Shifts, congruities and discrepancies in challenges in hospice and palliative care were identified between T0 and T1. Due to contact restrictions, important parts of end-of-life care were missing, and the roles of individuals providing hospice and palliative care were redefined. The interviewed groups experienced changes differently and contradictory statements on satisfaction and expectations about hospice and palliative care were reported. Employees and relatives predominantly perceived the pandemic to be very stressful, while residents endured this period more composedly. Employees stated that, despite the pandemic, they were mostly able to meet residents' requests. However, relatives and residents expressed that minor requests were not reliably fulfilled, neither at T0 nor at T1. Drawing together the different perspectives from employees, residents and relatives offers a bigger picture of challenges in hospice and palliative care in nursing homes and the pandemic effects. Stronger communication of requests and needs as well as greater collaboration, especially under crisis conditions, are essential for a better quality of end-of-life care. There is an urgent need to break down the taboos around the topics of dying and death in nursing homes.

[Implications for improving health care quality and patient safety of palliative residents in nursing homes: A qualitative study]. / Implikationen zur Verbesserung der Versorgungsqualität und -sicherheit von palliativen Bewohner*innen in der stationären Pflege: eine qualitative Studie.

INTRODUCTION: Despite the increasing importance of palliative care, the implementation of professional and ethical quality standards appears to be challenging for nursing homes, leading to different levels of palliative care between facilities. This study aims to examine the concrete problem areas of palliative care in everyday practice and to discover what is needed to improve health care quality and patient safety of palliative residents in nursing homes from different perspectives. METHODS: Semi-structured interviews with 14 employees and managers of two nursing homes in urban and rural areas in North Rhine-Westphalia were conducted and analyzed according to Mayring's qualitative content analysis. Additionally, characteristics of ideal-typical palliative care in nursing homes were identified from different perspectives through interdisciplinary focus groups of various involved professions. RESULTS: Due to a lack of structural and organizational guidelines, processes of palliative care are based on subjective actions of the staff, which leads to uncertainties and differences in the management of palliative care for nursing home residents. Besides limited time resources for care and support of residents at their end of life, this represents a major stress factor for employees. In the focus groups, characteristics of ideal-typical palliative care in the everyday practice of palliative care were identified. In terms of potential for optimization, palliative care pathways are seen as one way to contribute to creating a framework for palliative processes which at the same time leaves room for professional decisions in individual cases. DISCUSSION: It seems likely that inconsistencies in the management of palliative care processes can also be found in other nursing homes. Indications of this include the low proportion of residents with identified palliative care needs and the lack of use of assessments to identify palliative needs and to monitor typical palliative symptoms. At the same time, it must be taken into account that the last phase of life is characterised by individuality, which cannot and should not be standardised. In palliative care practice, professional perceptions and empirical knowledge are well needed. Nevertheless, in terms of quality of care, these should not be the sole basis for palliative action. CONCLUSION: Different levels of palliative care and employees' uncertainties indicate that palliative care practice in nursing homes requires a framework that helps staff to act more confidently and yet leaves room for professional action and decision-making in individual cases.

[Palliative and Hospice Care in Nursing Homes: Discrepancies Between Theoretical Framework and Everyday Practice]. / Palliativversorgung und hospizliche Begleitung in der stationären Pflege zwischen theoretischem Konzept und Praxisalltag.

OBJECTIVES: Despite the existence of a legislative framework, palliative care and hospice support in nursing homes vary widely. Although most nursing homes have palliative care concepts by now, they are rarely integrated into everyday practice. This study aims to examine differences in palliative and hospice care and to determine the causes of discrepancies between theoretical framework and everyday practice. METHODS: Based on a pilot project, in depth structural and process analyses of two nursing homes in urban and rural areas in North Rhine-Westphalia were conducted. In addition, three nursing homes of an extended group of providers as well as an expert advisory board was included to minimize (provider-) specific characteristics and to expand findings. RESULTS: Although the proportion of palliative residents and their average age was comparable, analyses revealed significant differences between the nursing homes regarding the palliative length of stay (213.2 days vs. 88.6 days) as well as the mortality rate of palliative residents among all death cases (26% vs. 63.6%). Furthermore, internal processes within the nursing homes differed vastly despite similar concepts and procedural instructions. As a result, palliative care formally started at an earlier stage in nursing home X. Besides that, the identification of palliative care situations, as well as communication, organizational processes and the inclusion of cooperation partners, took place without fixed structures and was based on the subjective handling of staff members in both facilities. CONCLUSIONS: It turns out to be challenging for nursing homes to implement theoretical framework into everyday practice. To facilitate this process, aside from practicable assessments, defined responsibilities and organizational support, financing concepts at health policy level need to be established.

[Extent of rationing and overprovision in stationary care: results of a nationwide survey of German hospitals]. / Ausmaß von Rationierung und Überversorgung in der stationären Versorgung.

BACKGROUND: Faced with economic pressure and with the insufficient funding of investments many hospitals are in deficit. However, there is little evidence whether these circumstances translate into rationing of services and which factors might be relevant in this context. Concerning the development of the number of patients it is also unclear, whether economic incentives lead to an overprovision of medical services. METHOD: Based on earlier studies and semi-structured interviews with hospital executives professional group specific questionnaires were developed and sent to almost 5.000 chief physicians, hospital managers and directors of nursing. The response rate was 43 %. RESULTS: All respondents perceived considerable economic restrictions. In consequence, 46 % of chief physicians have rationed useful services or replaced them by cheaper less effective alternatives. Although rationing is a concern in all medical disciplines the intensity is modest. Moreover, the chief physicians perceived a tendency to overprovision - especially in orthopedy and cardiology. CONCLUSION: Due to financial restrictions of health funds and federal states the economic pressure will stay high. This implies political actions to prevent negative consequences for patient care.

The effectiveness of interventions in workplace health promotion as to maintain the working capacity of health care personal.

BACKGROUND: The increasing proportion of elderly people with respective care requirements and within the total population stands against aging personnel and staff reduction in the field of health care where employees are exposed to high load factors. Health promotion interventions may be a possibility to improve work situations and behavior. METHODS: A systematic literature search is conducted in 32 databases limited to English and German publications since 1990. Moreover, internet-searches are performed and the reference lists of identified articles are scanned. The selection of literature was done by two reviewers independently according to inclusion and exclusion criteria. Data extraction and tables of evidence are verified by a second expert just like the assessment of risk of bias by means of the Cochrane Collaboration's tool. RESULTS: We identified eleven intervention studies and two systematic reviews. There were three randomized controlled trials (RCT) and one controlled trial without randomization (CCT) on the improvement of physical health, four RCT and two CCT on the improvement of psychological health and one RCT on both. Study duration ranged from four weeks to two years and the number of participants included from 20 to 345, with a median of 56. Interventions and populations were predominantly heterogeneous. In three studies intervention for the improvement of physical health resulted in less complaints and increased strength and flexibility with statistically significant differences between groups. Regarding psychological health interventions lead to significantly decreased intake of analgesics, better stress management, coping with workload, communication skills and advanced training. DISCUSSION: Taking into consideration the small to very small sample sizes, other methodological flaws like a high potential of bias and poor quality of reporting the validity of the results has to be considered as limited. Due to the heterogeneity of health interventions, study populations with differing job specializations and different lengths of study durations and follow-up periods, the comparison of results would not make sense. CONCLUSIONS: Further research is necessary with larger sample sizes, with a sufficient study duration and follow-up, with a lower risk of bias, by considering of relevant quality criteria and with better reporting in publications.