Towards a set of competencies in palliative care nursing in Spain: what's getting in the way of consensus?

BACKGROUND: Spain currently lacks a competency framework for palliative care nursing. Having such a framework would help to advance this field in academic, governmental, and health management contexts. In phase I of a mixed-methods sequential study, we collected quantitative data, proposing 98 competencies to a sample of palliative care nurses. They accepted 62 of them and rejected 36. METHODS: Phase II is a qualitative phase in which we used consensus techniques with two modified nominal groups to interpret the quantitative findings with the objective of understanding of why the 36 competencies had been rejected. Twenty nurses from different areas of palliative care (direct care, teaching, management, research) participated. We conducted a thematic analysis using NVivo12 to identify meaning units and group them into larger thematic categories. RESULTS: Participants attributed the lack of consensus on the 36 competencies to four main reasons: the rejection of standardised nursing language, the context in which nurses carry out palliative care and other factors that are external to the care itself, the degree of specificity of the proposed competency (too little or too great), and the complexity of nursing care related to the end of life and/or death. CONCLUSIONS: Based on the results, we propose reparative actions, such as reformulating the competencies expressed in nursing terminology to describe them as specific behaviours and insisting on the participation of nurses in developing institutional policies and strategies so that competencies related to development, leadership and professional commitment can be implemented. It is essential ​​to promote greater consensus on the definition and levels of nursing intervention according to criteria of complexity and to advocate for adequate training, regulation, and accreditation of palliative care expert practice. Locally, understanding why the 36 competencies were rejected can help Spanish palliative care nurses reach a shared competency framework. More broadly, our consensus methodology and our findings regarding the causes for rejection may be useful to other countries that are in the process of formalising or reviewing their palliative care nursing model.

[PHARMACOLOGICAL TREATMENT IN PALLIATIVE CARE. DRUG ADMINISTRATION ROUTE, CONTINUOUS SUBCUTANEOUS INFUSION, ADVERSE SIDE EFFECTS, SYMPTOM MANAGEMENT]. / Farmacoogía en Cuidados Paliativos.

OBJECTVE: To achieve well-being in patients in Palliative Care is required to know which are the most common symptoms, which are the drugs used for relief, which are the routes of administration of drugs that are suitable, how effective the drugs are and what incompatibilities, interactions and adverse effects occur. The aim of this article is to review the relevant issues in the management of the drugs commonly used by nursing in Palliative Care and presenting recommendations to clinical practice. METHODOLOGY: Management interventions drugs for nurses in Palliative Care recommended by the scientific literature after a search of Scopus, CINAHL, Medline, PubMed, UpToDate and Google Scholar are selected. RESULTS: The oral route is the choice for patients in palliative situation and subcutaneous route when the first is not available. The symptoms, complex, intense and moody, should be systematically reevaluated by the nurse, to predict when a possible decompensation of it needing extra dose of medication. DISCUSSION: Nurses must be able to recognize the imbalance of well-being and act quickly and effectively, to get relief to some unpleasant situations for the patient as the pain symptoms, dyspnea or delirium. For the proper administration of rescue medication, the nurse should know the methods of symptomatic evaluation, pharmacokinetics and pharmacodynamics of drugs, the time intervals to elapse between different rescues and nccocc rocnnnco t thocm

[RESILIENCE AND NURSE CARE]. / Resiliencia y, cuidado enfermero.

Resilience is a dynamic and evolving process, that varies according to the circumstances, the features of the trauma, the context, the stage of life in which the person is, culture and learning we had. Largely depends on the art of extending the arm to ask for help and also the art to attempt it with significant relationships. From the belief that the nursing profession is called to provide resilience tutoring, we review the keys by which we consider these professionals potential resilience tutors.

Resiliencia y cuidado enfermero / Resilience and nurse care

La resiliencia es un proceso dinámico y evolutivo, que varía según las circunstancias, las características del trauma, el contexto, la etapa de la vida en que la persona se encuentra, la cultura y el aprendizaje que hemos hecho en ella. En buena medida, depende del arte de tender el brazo para pedir ayuda y del arte de procurarla con relaciones significativas. Desde la convicción de que la profesión de enfermería está llamada a constituirse en tutoría de resiliencia, revisamos las claves por las que consideramos a estos profesionales potenciales tutores de resiliencia (AU)

Resilience is a dynamic and evolving process, that varies according to the circumstances, the features of the trauma, the context, the stage of life in which the person is, culture and learning we had. Largely depends on the art of extending the arm to ask for help and also the art to attempt it with significant relationships. From the belief that the nursing profession is called to provide resilience tutoring, we review the keys by which we consider these professionals potential resilience tutors (AU)

Gestión emocional y hábito reflexivo: en la relación de ayuda para el cuidado holístico del paciente paliativo / Emotional management and critical thinking in the aid relationship of the holistic care of palliative patients

Para cuidar a pacientes paliativos es fundamental que el profesional desarrolle competencias emocionales. Ello implica adquirir el hábito de la reflexión de sentimientos propios y ajenos para ser capaces de identificar emociones personales, de pacientes, familia y equipo. La reflexión entraña un esfuerzo continuo para razonar sobre los aspectos relativos a la práctica profesional, sobre todo en temas tan complejos como el sufrimiento y la muerte. Tanto el razonamiento reflexivo como la gestión emocional son vitales en la Relación de Ayuda. Para los profesionales de enfermería cuidar a nivel emocional significa tomar conciencia de los sentimientos propios y ajenos, llegar a comprenderlos y aceptarlos para poderlos gestionar adecuadamente. La actividad enfermera implica cualidades de competencia social, empatía, sensibilidad, habilidades comunicativas, honestidad, flexibilidad y capacidad de adaptación a las necesidades individuales de las personas cuidadas. En el contexto del cuidado de los pacientes paliativos y sus familias todos estos aspectos son fundamentales y forman parte de la filosofía de los mismos. La educación emocional en nuestra profesión sigue siendo un reto en la formación inicial y en la formación continua (AU)

To care for palliative patients is essential that healthcare professionals develop emotional competencies. This means acquiring the habit of self reflection and be emphatic with other people, in order to be able to identify the personal emotions of patients, family and team. Reflection involves a continuing effort to reason about aspects of professional practice, especially on issues as complex as suffering and death. Both reflective reasoning and emotional management are vital in an Aid Relationship. For nursing healthcare professionals, to care the emotional aspects means becoming aware of their own and others feelings, and get to understand and accept to handle them properly. Nursing actions involves many qualities of social competence, such as empathy, understanding, communication skills, honesty, flexibility and adaptability to the individual needs of people cared .In the context of palliative care patients and their families all these aspects are fundamental and are part of the same philosophy. Emotional education still remains a challenge in our profession both in the initial and continuing training (AU)

Atención enfermera en el sufrimiento espiritual refractario mediante el uso de la taxonomía nanda-noc-nic / Care nurse at refractory spiritual suffering using taxonomy nanda-noc-nic

En este trabajo se presenta el concepto de sufrimiento espiritual refractario en el paciente en situación terminal, los factores que influyen sobre el mismo, la posibilidad de su valoración y el abordaje de cuidados destacando el papel de la atención enfermera a la desesperanza para su identificación y alivio, mediante el uso de la taxonomía NANDA-NOC-NIC (N-N-N). Concluimos que se hace necesario incorporar a la rutina asistencial el screening del sufrimiento espiritual, su evaluación, prevención y su atención interdisciplinar. Cuando la enfermería desarrolla cuidados directos orientados a mejorar los niveles de esperanza se logra que el paciente terminal disminuya su sufrimiento espiritual. Ante un sufrimiento espiritual refractario es necesario plantearse la opción de una sedación paliativa en la que enfermería tiene un papel esencial tanto en su valoración para la indicación como en la administración y en la evaluación de sus efectos terapéuticos (AU)

This paper introduces the concept of refractory spiritual suffering in the terminal patient, the factors that influence it, the possibility of their assessment and care approach emphasizing the role of nurse care to despair for identification and relief through the use of taxonomy NANDA-NOC-NIC (NNN). We conclude that it is necessary to incorporate into the care routine screening of spiritual suffering, assessment, prevention and interdisciplinary care. When direct care nursing developed aimed at improving levels of hope that the patient achieves his spiritual suffering terminal decline. In refractory spiritual suffering is necessary to consider the option of palliative sedation in which nurses have a crucial role both in their valuation for the indication and in the administration and evaluation of its therapeutic effects (AU)

Cuidados integrales de los últimos días y horas de vida / Comprehensive care in the last days and hours of life

Este artículo identifica los elementos más significativos del proceso de atención enfermera a los últimos días y horas de vida en el contexto de una enfermedad en situación terminal previamente diagnosticada. Para ello se revisan las principales guías clínica de cuidados integrales y, en especial, la diseñada por el Hospital San Juan de Dios de Sevilla. Se concluye que es necesario saber identificar la fase de agonía para aplicar, en consecuencia, un plan asistencial predeterminado capaz de responder de forma personalizada a las necesidades específicas que se presentan en las últimas horas de la vida de un paciente en situación terminal. La actuación interprofesional continuada y coordinada sobre el paciente y la familia siguiendo estándares normalizados permite el logro de una muerte en paz y libre de un sufrimiento evitable (AU)

This article identifies the most significant elements of the process of nurse attention to the last days and hours of life in the context of a disease previously diagnosed like a terminal situation. For this object, we have reviewed the main clinical guidelines on comprehensive care and, especially, the guideline that was designed by the Saint John of God Hospital in Seville. We conclude that it is necessary to know how to identify the phase of agony to apply, therefore a default care plan that allows to respond customized to the specific needs that occur in the last hours of the life of a terminal patient. A continued and coordinated interprofessional assistance to patient and family following standardized standards allows achieving a peaceful death and free from avoidable suffering (AU)

Farmacología en cuidados paliativos. Vías de administración, mezclas, efectos secundarios frecuentes, normas básicas para el control de síntomas / Pharmacological treatment in palliative care. Drug administration route, continuous subcutaneous infusion, adverse side effects symptom management

Objetivo. Para lograr el bienestar del paciente en Cuidados Paliativos (CP) es obligado conocer cuáles son los síntomas más frecuentes, qué fármacos se utilizan para su alivio, cuáles son las vías de administración, qué efectividad demuestran y qué incompatibilidades, interacciones y efectos adversos. El objetivo de este artículo es revisar las cuestiones relevantes en el manejo enfermero de los fármacos comúnmente usados en CP y presentar recomendaciones orientadas a la práctica clínica. Metodología. Se seleccionan las intervenciones sobre manejo enfermero de fármacos en CP recomendadas por la literatura científica tras una búsqueda realizada en Scopus, CINAHL, Medline-Pubmed, UpToDate y Google Académico. Resultados. La vía oral es la de elección en el paciente en situación paliativa, y la subcutánea cuando no está disponible la primera. La sintomatología, compleja, intensa y cambiante, debe reevaluarse de forma sistemática por el profesional de enfermería, y contrarrestar posibles descompensaciones impredecibles de la misma con una dosis extra de medicación. Discusión. El personal de enfermería ha de saber reconocer la descompensación y actuar rápida y eficazmente en el alivio de una sintomatología tan desagradable para el paciente como el dolor, la disnea o el delírium. Para la administración correcta de la medicación de rescate, el personal de enfermería debe conocer los métodos de evaluación sintomática, las características farmacocinéticas y farmacodinámicas de los fármacos, los intervalos de tiempo que deben transcurrir entre diferentes rescates y evaluar la respuesta a los mismos (AU)

Objective. To achieve well-being in patients in Palliative Care is required to know which are the most common symptoms, which are the drugs used for relief, which are the routes of administration of drugs that are suitable, how effective the drugs are and what incompatibilities, interactions and adverse effects occur. The aim of this article is to review the relevant issues in the management of the drugs commonly used by nursing in Palliative Care and presenting recommendations to clinical practice. Methodology. Management interventions drugs for nurses Palliative Care recommended by the scientific literature after a search of Scopus, CINAHL, Medline, PubMed, UpToDate and Google Scholar are selected. Results. The oral route is the choice for patients in palliative situation and subcutaneous route when the first is not available. The symptoms, complex, intense and moody, should be systematically reevaluated by the nurse, to predict when a posible decompensation of it needing extra dose of medication. Discussion. Nurses must be able to recognize the imbalance of well-being and act quickly and effectively, to get relief to some unpleasant situations for the patient as the pain symptoms, dyspnea or delirium. For the proper administration of rescue medication, the nurse should know the methods of symptomatic evaluation, pharmacokinetics and pharmacodynamics of drugs, the time intervals to elapse between different rescues and assess response to them (AU)

Comunicación con el enfermo terminal / Communication with terminally ill patient

En todo el proceso de relación equipo-enfermo-familia la comunicación es un instrumento terapéutico esencial y principalmente en la transmisión de malas noticias. La comunicación no es la mera transmisión de información. Es un proceso cuyo objetivo es permitir la adecuación del enfermo y la familia a su situación real y donde el qué, el cómo y el cuánto se quiere saber lo marca el propio paciente. A lo largo de este artículo, expondremos algunas reflexiones que el equipo tiene que tener muy en cuenta a la hora de informar al enfermo. Explicaremos el protocolo SPIKES o su versión española, EPICEE: protocolo de 6 pasos, base de los procedimientos recomendados por los expertos para dar malas noticias. Y, por último, hablaremos de la conspiración de silencio, una de las situaciones más frecuentes y difíciles de manejar en el día a día debido al paternalismo por parte de profesionales y familiares, en el que ambos prefieren ocultar al enfermo su situación, al pensar que es lo mejor para él (AU)

The communication is a essential therapeutic instrument in every process of relationship in the team patient-family, and mainly in the transmission of bad news. The communication is not just a simple transmission of information. It is a process whose goal is to enable the adaptation of the patient and family to their actual situation and where the «what», «how» and «how much do you want to know», are belonged to the own patient. Along this article, we will expose some thoughts that the team has to take into account when informing the patient. We are going to explain the SPIKES protocol, or its Spanish version EPICEE: 6-step protocol, based on those recommended by the experts to deliver bad news procedures. And finally we’ll talk about the conspiracy of silence, one of the most common and difficult situations to handle in day to day due to paternalism by professionals and families, in which they prefer to hide the situation to the patient, thinking it’s the best for him (AU)

Actuación de enfermería ante el cuidado físico en el paciente terminal / Nursing action before the terminal patient physical care

Los cuidados paliativos son acciones ejercidas por los profesionales de enfermería para aumentar el confort y bienestar en pacientes con enfermedad terminal. La OMS define estos cuidados como «El enfoque que mejora la calidad de vida de los pacientes y familias que se enfrentan a los problemas asociados con enfermedades amenazantes para la vida, a través de la prevención y alivio del sufrimiento por medio de la identificación temprana e impecable evaluación y tratamiento del dolor y otros problemas físicos, psicológicos y espirituales» [1]. La precursora de los cuidados paliativos fue Cicely Mary Strode Saunders, quien explica la necesidad de modificar las Unidades de Cuidados Paliativos para mejorar la calidad de vida de los pacientes irreversibles. Los cuidados paliativos son necesarios en pacientes que presentan una enfermedad en situación terminal. El pronóstico de vida en este tipo de situaciones es inferior a seis meses. Se considera al ser humano un modelo biopsicosocial. Es por esta razón que el profesional de enfermería debe atender a todas las necesidades derivadas de estas tres dimensiones de la persona. En este artículo abordaremos los cuidados paliativos en el paciente terminal, teniendo en cuenta la faceta el profesional de enfermería como referente en la enseñanza de los cuidados al cuidador principal (AU)

Palliative care is a group of actions performed by nurses in order to increase the comfort and well-being of patients with terminal illnesses. The World Health Organization (WHO) defines this term as: «An approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual [1]. Cicely Mary Strode Saunders is considered as the precursor of the palliative care, who explained the need to change the Palliative Care Units in order to improve the quality of life of patients with terminal illnesses. Palliative care is necessary for patients with a terminal illness. In such cases, the life expectancy is less than six months. Human being is considered a biopsychosocial model. For this reason, the nurse must take into account all the requirements arising from these three dimensions of the human being. In this essay, we deal with palliative care in patients with terminal illnesses, considering the role of the nurse as an important reference when teaching palliative care to the main carer (AU)

En la habitación 324 / At room number 324

Hola, me llamo Rosa y tengo cáncer de mama. Mi historia comenzó en una simple revisión rutinaria. Recordaré toda mi vida esa mismas palabras que lo cambiaron todo: «Tiene usted cáncer de mama».Se realiza una descripción de las fases por las que pasa un paciente en una enfermedad terminal, a propósito de un caso clínico. Intentamos adentrarnos en el mundo de los sentimientos, dejando atrás el aspecto clínico de la enfermedad (AU)

Hello, my name is Rosa and I have breast cancer. My story begins at a general medical examination. I will remember for my whole life the exactly worlds that changed everything: «You have breast cancer». In relation to a case a description of the stages that patients who are suffering from a terminal illness use to go through. We try to go in depth into the feelings world, illness clinical details are leaving behind (AU)

Cuestiones éticas de enfermería en cuidados paliativos / Nursing ethics issues in palliative care

El objetivo de este trabajo es describir las categorías antropológicas esenciales de la enfermedad terminal así como las principales actitudes enfermeras para su cuidado y los criterios éticos para la indicación y aplicación de terapias paliativas. Se concluye que las categorías antropológicas del proceso de morir fundamentan las actitudes éticas de la atención enfermera en Cuidados Paliativos; el acceso que concede el enfermo y la familia sobre su intimidad a la actuación enfermera genera un contexto relacional donde la comunicación se puede hacer más efectiva y, de esta forma, se facilita el afrontamiento existencial, espiritual y psicosocial del enfermo, así como el proceso de información diagnóstica y pronóstica. La información clínica cualitativa y cuantitativa aportada por el profesional de enfermería al equipo multidisciplinar sobre la evaluación de la efectividad de los resultados de los cuidados y las terapias dentro del contexto de la asistencia a la enfermedad terminal permite ajustar un plan terapéutico éticamente adecuado (AU)

The aim of this paper is to describe the essential anthropological categories of terminal illness and the main attitudes of nurses for their care and the ethical criteria for indication and application of palliative therapies. We conclude that ethical attitudes of care in palliative care nursing are based in anthropological categories of dying process; the access granted to nurse by the patient and family within their privacy generates a relational context where communication can be made more effective and thus facilitate the coping existential, spiritual and psychosocial in illness and the process of diagnostic and prognostic information. The qualitative and quantitative clinical information provided by the nursing professional to multidisciplinary team on the evaluation of the effectiveness of care outcomes and therapies in the context of terminal illness assistance allows establishing a plan of treatment appropriate ethically (AU)

[AT ROOM NUMBER 324]. / En la habitación 324.

Hello, my name is Rosa and I have breast cancer. My story begins at a general medical examination. I will remember for my whole life the exactly worlds that changed everything: "You have breast cancer". In relation to a case a description of the stages that patients who are suffering from a terminal illness use to go through. We try to go in depth into the feelings world, illness clinical details are leaving behind.

[NURSING ACTION BEFORE THE TERMINAL PATIENT PHYSICAL CARE]. / Actuación de enfermería ante e culdado físico en el paciente terminal.

Palliative care is a group of actions performed by nurses in order to increase the comfort and well-being of patients with terminal illnesses. The World Health Organization (WHO) defines this term as: An approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual [1]. Cicely Mary Strode Saunders is considered as the precursor of the palliative care, who explained the need to change the Palliative Care Units in order to improve the quality of life of patients with terminal illnesses. Palliative care is necessary for patients with a terminal illness. In such cases, the life expectancy is less than six months. Human being is considered a biopsychosocial model. For this reason, the nurse must take into account all the requirements arising from these three dimensions of the human being. In this essay, we deal with palliative care in patients with terminal illnesses, considering the role of the nurse as an important reference when teaching palliative care to the main carer.