Four categories were isolated. Three categories reflected the benefits of SHARE (relationships), knowledge exchange, communication), while barriers to SHARE are reflected under the category challenges. Categories and subcategories are portrayed in Figure 1.
A common topic from all the logs was the building of relationships – of facility staff with residents, and with families, connections among facility staff, and in the case of the hospice nurses, the importance of building a strong connection with the facility staff in order to build trust.
Palliative care nurse specialists and long-term care registered nurses - The establishment of relationships between the palliative care nurse specialists and long-term care facility registered nurses, helped develop a sense of both trust and understanding of the role and scope of hospice in the care of residents.
SHARE helped the long-term care facility team and myself developing a better rapport. Particularly in my relationship with care staff, they would share with me about their wedding anniversaries and family’s struggles. I sensed that there was added meaning to their work somehow.
The following quote highlights the need for the reinforcement and support provided by the palliative care nurse specialist as illustrated by this example of the isolation within which facility registered nurses often work.
Long-term care facility nurse was working in such a lonely environment. I could see the joy in the eyes of RN’s [registered nurses] [name] and [name] when I listened to them. When I gave RN [name] my honest praise about her kindness and compassionate care to her elderly resident, she actually had tears. She was very humbled and said, “I was doing my job. I thought I was doing what everyone does!” Such beautiful and caring nurses!
Role of Facility Managers – Support for SHARE on the part of facility managers fostered closer relationships between registered nurses, health care assistants, and managers. The strengthened relationship managers, in turn, facilitated greater collaboration with the palliative care nurse specialists:
One [health care assistant] in particular whom I found to be very prickly when I first started visiting [facility] and how her demeanor had changed over the last 12 months. When I walked in today, I could hear her laughing and joking with the staff and she even came up and gave me a hug. I put that down to the way that [manager] has been managing and supporting the staff and the improvements she has made within the facility.
Feeling like a Family - Opportunities for participation in activities encouraged socialization between facility staff members (RN’s, HCA’s) and between staff and residents. These activities provided a mutual feeling of “family” that fostered the development of collaborative relationships, a key prerequisite for SHARE success.
It was clear which facility did want to involve residents ’family.’ When Nurse Manager A announced Christmas decoration competition in individual Suites, I could hear that the focus was on the dignity of residents…Looking at the staff involvement in their own party and the trolley filled with Secret Santa, I felt this place was full of love...If staff were not happy, they wouldn’t bother to participate in Secret Santa or Share lunch.
Reciprocal learning -The sharing of palliative care knowledge and applied between the hospice nurses and the long-term care facility staff and growth in hospice nurses' understanding of geriatric care was evident in the logs. The hospice nurses’ perspectives on care in long-term care facilities revealed new understandings of geriatric care and the palliative care trajectory of chronic illness with all of its uncertainty.
The learning from SHARE discussions with [name] [RN] has been most beneficial to inform my knowledge to a broader level of the “strength of the human spirit to survive when the body and mind are dying” especially with reference to those who have dementia and advanced frailty.
Situated contributions -There is considerable evidence of situated interventions by the hospice nurse where the hospice nurses’ deliberate presence in the long-term care facility created plentiful moments where discussion, learning, teaching, and changes in practice took place.
It was quite rewarding to see RN [name] come up with the resident for Palliative Care Register. This RN team worked quietly and never showed any excitement on the SHARE visit. Thus, when they voluntarily gave me a name “[Hospice Nurse], I think this resident was ready for a palliative care approach…”I was quietly joyful. Without SHARE, this facility had not been offered palliative care education in the past and (a hospice) community team had not been in touch for at least two years.
Other insights for the hospice nurse indicated areas for further education. This was particularly true in regard to maintaining ongoing communication with families about changes in their relative’s condition and care needs.
I was surprised that the predominance of residents reviewed was by default as ”For Resus” [resuscitation]…RN/facility under the impression of the resident is unable to cognitively decide rendered them as ‘resuscitatable’ rather than working with the family as part of ACP [advance care planning] process.
Quality – Registered nurse confidence in communication skills with regard to palliative and end of life care as well as the ability to initiate advance care planning with families improved in some facilities. One hospice nurse reflected on both the improved palliative care knowledge and communication skills of a registered nurse:
The long-term care facility team had been very caring for him [resident] and kept close communication with him [resident] and his son. RN [name] was able to share with me that the resident [name] and his son discussed funeral arrangements in the last 48 hours. She felt particularly proud of able to recognise dying and facilitate communication amongst resident and his son.
Early palliative care needs identification -The logs also provided evidence of better documentation of residents with palliative care needs. Better identification allows for proactive care planning before the terminal stage.
When I was preparing for the resident's information for a research report, I realised that all recent deceased residents were enrolled onto Palliative Care Register.
Key themes reflected throughout the logs included the detrimental effects of resource constraints and increasing staff turnovers. These factors not only influence palliative care education and delivery but also staff well-being.
Staff turnover, & under-resourcing -The level of reference to staff turnover, insufficient staffing & staff changes (especially RNs coming in from overseas who use the long-term care sector to bridge into work in district health boards) is troubling. This, in turn, led to very challenging circumstances in which to provide staff education in a traditional classroom sense, making the physical presence of the hospice nurses even more significant in sharing knowledge and practice between the long-term care facilities and the hospice nurses.
The lead clinical nurse in the Dementia Unit has left. Find this unfortunate as she appeared to us to be very knowledgeable in the care of those with dementia. They do not have someone to replace her as yet.
The continuing staff shortages serve as a further indicator of the need for an alternative to traditional didactic methods of teaching. Staff shortages translate into a lack of staff available to attend sessions, as indicated in the following reflection:
Even CCM [clinical charge nurse manager] A could honestly share that she was constantly orientating a new group of nurses. They were not in any shape to take on [education] training at all.
Documentation - Problems persisted in some facilities particularly in relation to future care documentation. The palliative care nurse specialists in the SHARE study documented practices that they found troubling concerning palliative care and especially unnecessary hospital admission.
A new nurse was on duty and there were no clear easy to access guidelines in residents' notes about her future plan of care. Therefore, by default, she went to the hospital where she spent 24 hours, was commenced on oral antibiotics and then returned to the facility.