Wish for promoting high-quality palliative care
Sustaining knowledge and experience
The data showed that the participants perceived that their colleagues, and students in practical placement as well, change their view of palliative care and gain more interest in the field when, as resource nurses, they conveyed knowledge and experience in palliative care. They also experienced that they could ease the anxiety of nurses having less experience in palliative care.
«An assistant nurse student (…) she was very insecure about caring for dying patients and everything (…) Then there were a lot of questions we talked about. She said it had affected her and that she had become more interested in this subject, and doesn’t think it was that scary any longer”.1
The data showed that the resource nurse is able to support the next of kin and contribute to good memories when they follow their loved ones during the last days of life. However, the resource nurse may face uncertainty in their role. Knowledge of palliative care and good communication abilities were highlighted as prerequisites to being able to handle the different situations properly.
Communicating good practice
It was further described that competence development is crucial to achieve high-quality palliative care. New colleagues and students need teaching, and routines must be observed. The participants used their experience and knowledge to talk about and demonstrate good practice.
According to the participants, the members of the palliative care team (in this context: physician, nurses and assistant nurses) need to have a uniform, shared view of quality to be able to share the same professional goals and a common language of palliative care.
«To work with competence is crucial (….) to have a shared view of quality about what is to be done (…) and that we are able to speak the same language”. 2
Challenges with reflection in the palliative care team
The virtue of reflection
The data highlighted the inherent need for ethical reflection in palliative care. The personnel are affected by the work and need time to reflect, and reflection makes colleagues more conscious of what they are doing. If the palliative care team does not reflect, the quality of the work is at risk. Reflection in the palliative care team facilitates reaching a common view of central issues in palliative care, eg nutrition and hydration when the patient is close to death.
“I think it is great working together with others who hold the same basic view. We discuss, we might disagree; that is the way it should be, but we basically agree on how we want it to be”. 3
The data showed that when receiving a discharged patient from the hospital, brief information like the diagnosis and need of care provides how nurses and physicians understand the patient. In such situations the palliative care team needs to cooperate to reach a broader understanding of the patient and their situation.
“It’s very exciting to hear why you do things that way or what you were thinking to reach that conclusion”. 4
Spontaneous reflection and planned reflection
The data showed that the resource nurses were enthusiastic after the workshop facilitated by the external expert, and that they were dedicated to performing reflection regularly. Even though, the data showed it turned out to be difficult performing reflection regularly as the colleagues of the resource nurse yielded resistance when it came to systematic reflection. The planned and systematic reflection may invoke fear in the participants, and the structure itself, eg turn taking, can impede the reflection. Spontaneous reflection about specific, experienced situations facilitates better conversations than general discussions about professional or ethical issues. Regardless of the benefits of spontaneous reflection, the data showed that the resource nurses experienced the power in systematic reflection when they were supervised by the external expert at the workshop. The data described that the structure in the systematic reflection, eg taking turns in a roundtable discussion, gives everyone a chance to speak – both those who speak easily in groups and the quiet participant who has to be gently prodded to make his or her opinion known. The members of the palliative care team perceive situations differently, and with open-ended questions, it is possible to talk through difficult situations as well as good situations. The participants stated that whereas the resource nurse normally wants regular reflection sessions, the members of the palliative care team more often reflect spontaneously in situations, or after report, rather than systematically according to a plan. Nevertheless, the reflection related to “here and now situations” has the potential to be both systematic and deep. Reflection in general provides an opportunity to enhance one another’s skills and to become stronger as a team.
The data also showed that it frequently happens, when reflection is scheduled, that something comes up and the reflection is postponed. It was mentioned that the palliative care team ought to maintain a positive attitude towards reflection. If a team member has a negative attitude towards it, the resource nurse may become disheartened.
The importance of collaboration in the palliative care team
Collaboration with the physician
The data described how collaboration in the palliative care team can potentially affect quality of care. Over time, resource nurses and the nursing home physicians share common experiences and reach a shared consensus, eg regarding alleviation of pain. When the nursing home physician has knowledge about the patients and the palliative care team share a common view, collaboration is easy. In situations where the nursing home physician is not available and the resource nurse has to consult a physician from the casualty ward, who is often pressed for time, the casualty physician usually does not know the patient or the situation. In cases like these, collaboration is far more difficult. The resource nurses try to avoid calling the casualty physician and instead plan ahead together with the nursing home physician. When a patient situation changes, they know what to do, eg to avoid transfer to hospital when relief is possible in the nursing home, the informants said.
They also said that resource nurses and physicians occasionally have differences in opinion. The physician may want to continue life-prolonging treatment, but the resource nurse recalls, after several conversations with the patient, that he has expressed that he does not want to live any longer. According to the informants, some physicians leave little room for dialogue, while others are more open minded. The resource nurse shows courage in interprofessional collaboration, applies her competence and presents arguments in a respectful way. The participants defend the nurse’s perspective and what they perceive as the best interest of the patient, but in the end the resource nurse respects the physician’s decision.
“Sometimes there is a little overtreatment (…) if you have enough experience to say that you disagree, you get a discussion where a physician must reconsider his or her decision (…) but if you don’t have the knowledge, you don’t have the experience or you don’t have the courage, then it won’t be any discussion”. 5
The data from the interviews revealed that the nursing home physician has a limited amount of time on the ward and that the resource nurses take care of conversations with the patients and family relatives that they consider is the physician’s responsibility.
“I wish the nursing home physician would stay here longer, that we had more access to him, that he had more time to visit all the patients, but this is how things are and we have to make the best of it”.6
They perceived that the physician acknowledges the resource nurse’s competence and trusts the resource nurse, but the resource nurses often want the physician to be more present in conversations about medical issues. The data indicated that their competence can at times be stretched to the limit when it comes to administration of medicines and information to next of kin.
Collaboration with colleagues
The data showed that nurses occasionally have different opinions about assessment of the patient and his or her condition. In situations involving ethical dilemmas, nurses may have differences of opinion as to how they interpret the situation and what action to take. The resource nurse may contribute by listening to their colleagues and reach a consensus through discussions, according to the informants.
The data also revealed that the resource nurse has to manage inappropriate attitudes. Professional routines and procedures go out-of-date, but some nurses keep doing the work as they always have done. Especially the personnel who have the longest service tenure do not want to listen to new thinking. The resource nurses perceived, however, that they could positively affect their colleague’s attitudes if they adopted a respectful manner.
Factors affecting the function of the resource nurse
The data showed that the ward nurse affects the function of the resource nurse, as they have to prioritise competence maintenance in the palliative care team. In addition, it is important that the ward nurse appreciates the work of the resource nurse and allocates time so that he or she is able to perform well. It is stressed that mutual trust between ward nurse and resource nurse is a prerequisite.
“(The ward nurse) (….) must be able to see the value of it (the work of the resource nurse), the common goal that this work enables good nursing performance”. 7
The data showed that days when there is a shortage of staff make it difficult for the resource nurse to deal with problems, compared to days with proper staffing.
The data showed that the network of resource nurses contributes to building competence and enhances team spirit.
“I think we need unity; I think we need these network meetings. We need to (….) become aware about what we are supposed to supervise others in doing or initiate in others”. 8