Alongside these are the rights to maintaining maximum quality of life [6, 18] and independence [9, 19], being treated with dignity [19, 20], given privacy [14, 21] and feeling safe and secure [22, 23]. 2006;54:700–9. As Ellen (RGN) and Hazel were helping Wendy to get ready for her trip out of the hospice, she started to talk about going to the shops: Wendy was talking excitedly about going to the shops after her x-ray, ‘but I’m not sure how long I'll be, I do get very weak all of a sudden and if that happens I’ll just need to come back’. Development of nurses' abilities to reflect on how to create good caring relationships with patients in palliative care: an action research approach. Andrea’s early warning signs were recorded on a chart (see Table 1), incorporating the progression of symptoms and outlining what actions should be taken to prevent an escalation of Andrea’s problems. Int J Palliat Nurs. Correspondence to After four months she was persuaded to attend the local community mental health centre but became suspicious of the psychiatrist who offered to increase her medication. Designing and conducting mixed methods research. []. The nurses were observed using different responses during most episodes of care, ranging from one type of response to all four. Springer Nature. Nurses adopted a range of ways of ‘diverting’ PNs, for example, focussing on only one of a number of needs; offering practical solutions; and acting upon different care aims. All authors were involved in data interpretation. The nurse put aside what she, and other members of the hospice staff, felt would be best for Bruce. A reflexive diary was kept throughout the duration of the study to identify and balance researcher bias. They are expected to address emotional and psychosocial needs and provide support and guidance to improve coping (Kirkevold 2010). Gold RL. Psychosocial interventions targeting the caregivers of cognitively impaired elderly patients with dementia not only reduce caregiver burden but also influence many patient- or caregiver-related outcomes. An exploration of the concerns of patients with inoperable lung cancer. In these excerpts of documentation both RGNs recognised that Eliza was unhappy with her current situation. However, their solution to this problem only had a temporary effect: Eliza’s boredom returned later that day and the move of rooms did not help her to accept her changing condition. All qualitative data relating to encounters were entered into an NVivo electronic qualitative analysis software project and descriptive analysis [49] began during transcription of the first observation. There was little opportunity to influence the treatment plan and a perception that they had done something wrong. There was no opportunity to reflect upon Andrea’s strengths and coping strategies that had been learnt between admissions. Andrea was diagnosed with schizophrenia shortly after her 21st birthday. Williams AM, Irurita VF. You will serve individuals who have physical disabilities and cognitive impairments, those who are recovering from a short-term illness or injury and those who are impacted by chronic conditions and co-morbidities, folks who will return to their homes and those who are receiving care in the last home. 2010;25:210–28. Rogers A, Karlsen S, Addington-Hall J. Ellen said ‘okay, but if you change your mind before you go, just say.’, Hazel: “Sometimes [nurses] persuade you to do things, such as when you went out the other day taking the wheelchair with you. There was also a statistically significant lower proportion of expression PNs that were immediately ‘dealt’ with (as opposed to ‘ducked’, ‘deferred’ or ‘diverted’) compared with the other types of PNs (χ2 = 6.18, p = 0.01). 227 encounters within 38 episodes of care were observed among 38 nurses and 47 patients. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. This study is limited in that it only gives an overview of the PNs observed by one researcher, in one hospice ward, using convenience sampling. ‘Coping’: The need for patients to have understanding and acceptance of their condition and their approaching death, whilst maintaining hope. Other researchers have inferred the presence of PNs by discussing patients’ and/or nurses’ views about their experiences of care [8–10], with studies that assess satisfaction or quality of care assessment arguably also falling within the psychosocial sphere [11, 12]. Psychosocial assessment is an important step towards creating a health care plan, especially for patients in palliative care. Elsevier Mosby: St. Louis; 2009. In these circumstances no recognition was made by the nurse of the existence of the patient’s PN at the time it was expressed. Palliative care, in particular, has psychosocial care as an essential focus [3–5]. Watson R. So you think you care? 2006;43:1011–22. Patients who were cognitively intact, and not thought to be in the last few days of life, were offered an information sheet outlining the research. Bruce said ‘there is one thing nobody's ever told me: what the results of those x-rays were that I had four weeks ago’. Copenhagen: WHO; 1991. International Council of Nurses. Nurse documentation and discussions around the observed PNs were also recorded, including shift handovers and multidisciplinary meetings. Chapple A, Ziebland S, McPherson A. However, no claim is made that this is an exhaustive list of PNs, or that these findings are generalisable to other settings. London: SAGE Publications; 2001. p. 369–81. Edinburgh: CSBS, 2002. You don’t have to use it, but it would be there as a safety-net and if you do get too weak your husband can push you round in it. Radbruch L, Payne S, the Board of Directors of the EAPC. Glickman M. Feeling Better Psychosocial Care in Specialist Palliative Care. When nurses used a ‘diverting’ response, the support they offered did not correspond with meeting the expressed PN: the nurses’ actions were aimed at meeting another need, which was not necessarily psychosocial. Baillie L. Practical nursing skills: a caring approach. This subtle expression of PNs contributes, at times, to the inability of nurses, in this study and others [31, 54], to recognise a request for psychosocial support. Wilson F, Ingleton C, Gott M, Gardiner C. Autonomy and choice in palliative care: time for a new model? This occurred when Stuart, a patient whose mobility was deteriorating, wished to focus on improving his current mobility. Oncology nurses' perceptions of obstacle and supportive behaviours at the end of life. Bryman A. These include anxiety and depression. 1) Psychological Sessions or Therapies PubMed  Appl Nurs Res. After inpatient treatment she remained in remission for seven years. She appeared despondent about this. This approach resulted in a large convenience sample with a high degree of variety [45, 47]. This is our chance to order treatment within our scope of practice for the patient. The nursing role in holistic care is to attain and maintain wellness by supporting not only physiological needs, but the psychological and psychosocial needs of the individual. Casey D, Murphy K, Leime AN, Larkin P, Payne S, Froggatt KA, et al. Patients had active, progressive, non-curative diseases (90 % had a malignancy; the majority of the remaining patients had a neurological illness). The findings indicate a need to plan future interventions to provide nurses with both skill development and support to improve their ability to integrate psychosocial care, which will improve patient outcomes. With family support, she gained a university place but two years into the course her boyfriend left her. In some cases, they would get another member of staff to deal with the PN because they felt that the other HCP had better skills or knowledge to deal with that situation. There is an important link between psychosocial care and overall health in seniors. In: Baillie L, editor. The psychosocial assessment helps the nurse determine if the patient is in mental health or a mental illness state. Terms and Conditions, These included developing an understanding of Andrea’s early warning signs and crisis planning to pre-empt problems. In both cases, our primary need is to find out an effective treatment to cure the disorders related to mental health. Fitzsimons D, Mullan D, Wilson JS, Conway B, Corcoran B, Dempster M, et al. J Adv Nurs. J Adv Nurs. Heyl BS. Patient sampling occurred by chance by being the first consenting patient to express a PN to the observed nurse that shift. Recommendations from the European Association for Palliative Care. In fact, cancer is commonly referred to as a disease affecting the family who travel the cancer journey together [15–17].Across the cancer journey, family members who become caregivers are known to provide the vast majority of home care [18–20]. The first way nurses ‘diverted’ was by dealing with only part of a patient’s requirements, rather than addressing the patient’s full range of needs. On each shift, a nurse was selected to be observed, depending upon her availability over the subsequent days for interview. In Standard 6 of the National Service Framework for Mental Health (Department of Health, 1999), all carers have a right to have their needs assessed and be involved in their relative’s treatment plan. She lost interest in studying, began drinking heavily and replaced her prescribed medication with illegal drugs. The 4D categorisation demonstrates for the first time how PNs are responded to in practice. The RN may lead and participate in support groups and counseling ses… Psychosocial intervention has become a valued dimension of immediate and long-term disaster response all over the world. Psychosocial Needs of the Elderly Learner’s Guide GOAL: You will learn the special psychosocial needs of the elderly and strategies that can be used to help you give person-centered care. Mood State CAA Care Area Assessment and Trigger Module. 'All the services were excellent. When they had finished the conversation I asked Marianne about it. Brereton L, Gardiner C, Gott M, Ingleton C, Barnes S, Carroll C. The hospital environment for end of life care of older adults and their families: an integrative review. The varied use of the 4Ds by individual nurses, even within one episode of care, indicates response does not depend upon nurses’ roles, education or belief that ‘it was their place to provide psychosocial support’. Aust J Adv Nurs. ‘Dealing’ encounters also occurred when psychosocial support was provided by the nurses adapting their behaviour, and/or actions, to provide care in a way that was preferred by, but not essential for, a patient. 2009;15:134–41. 2012;19:711–3. 2009;29:42–6. It is when the human element comes in that things go wrong': dissatisfaction with hospital care in the last year of life. J Adv Nurs. Dying well: factors that influence the provision of good end-of-life care for older people in acute long stay settings in Ireland. Creswell JC, Plano Clark VL. Nina related her inability to recognise Eve’s PNs to her lack of education concerning what PN are. Mental health is a state of well-being where there is the ability to deal with the typical stresses of life, works productively, and contribute to their community. Within these encounters, 330 PNs were expressed. ACCNS Journal for Community Nurses. Palliat Med. All authors read and approved the final manuscript. After at least 24 hours, during which time patients were encouraged to discuss the study with their significant others, they were approached for written consent. Every nursing home serves residents with diverse needs. 2006;57:77–86. Nurs Inq. 2011;68:981–93. What classifies Evie’s response as a ‘deferring’, rather than ‘ducking’, response is that immediately following Bruce’s episode of care, she reported his concern to a doctor. The first seven interactions formed a pilot study. In Andrea’s case her parents had ‘stalled’ her admission, sought a second opinion, did not accept superficial information from staff and subsequently faced negative attitudes and a reputation for being interfering and troublesome. 2. Time was identified as the number one barrier to psychosocial care. Oxford: Oxford University Press; 2012. p. 3–15. The outcome of this was a frustrated and mistrusting patient, a husband who agreed with a foregone conclusion, and a nurse who had to obey the paternalism from the ward hierarchy and duck the patient’s PN. Try not to worry about that just now.’. Int J Palliat Nurs. Google Scholar. Some patients liked to be told about everything the nurse was doing for them, whereas other patients preferred the nurse to ‘just do things’. Geneva: ICN; 2013. Nurs Ethics. The aim of this study was to provide a descriptive exploration of how psychosocial needs (PNs) of patients in a hospice ward are expressed and met, in order to develop an understanding of the provision of psychosocial support in practice. By using this website, you agree to our When intervening, it’s important to remember just how important the role of primary care professionals really is. Nevertheless, few nursing interventions have been developed to address the psychosocial wellbeing of stroke survivors (Burton and Gibbon 2005; Forbes 2009; Watkins et al. Staff on the ward felt there was limited time for listening to the experiences of patients and their families. HH designed the study, carried out the fieldwork and wrote the first draft of the paper. 2008;61:71–80. Teresa was very upset. In Andrea’s case, it was important to find the time to engender a supportive relationship and let her know that her concerns were being taken seriously. Sign in or Register a new account to join the discussion. This paper also demonstrates how nurses respond to PNs. 2012;18:597–605. As for risk nursing diagnoses, interventions should focus on reducing the client’s risk factors. The team felt constrained by Andrea’s wish not to have her parents involved and were divided about the issue of confidentiality. Soc Sci Med. In one instance, a nurse who possessed the knowledge and skills to carry out psychosocial support and was observed on other occasions dealing with some very complex PNs, reported that she can temporarily lose her ability to respond to PNs: Annie: “there [have] been times when people have given me cues and I’ve been aware that I’ve not picked up on [them], maybe because of the way I’ve been feeling at the time myself”. Chi squared tests were carried out to determine whether type of PN (rights, identity, coping, and expression) was related to the nurses’ responses (‘dealing’, ‘deferring’, ‘ducking’, or ‘diverting’). Palliat Med. Utilising ideas generated by Furlong and Leggart (1996) it was deemed important to gain a comprehensive account of the family’s experience. Andrea and her family were shown how they could anticipate and manage potentially stressful experiences. This study has demonstrated that patients’ PNs are rarely expressed to nurses as a standalone entity, which is how they are usually explained in nursing textbooks [51–53]. After this conversation Ann told me ‘it was important that Bruce had the opportunity to make that choice’. Stressful events were linked to Andrea’s personal experiences of increased psychosis. 2010;27:20–30. Despite numerous studies identifying the PNs expressed by palliative care patients, there is very little empirical evidence on how nurses actually provide psychosocial care in practice alongside their other duties in busy ward environments [19, 39, 40]. Many families are initially very suspicious of mental health professionals when they are asked to offer support, especially if in the past they have experienced a crisis, called for help and not gained an appropriate response. Care in nursing. SAGE: Los Angeles; 2014. The common factor in all of the ‘dealing’ encounters is that the nurse immediately supported the patients’ PNs. 2011;38:189–98. Information sheets were distributed to all registered (RGN) and auxiliary (AuxN) nurses working day-duty on the ward and 38 (88 %) gave written consent for their care to be observed. The health care sector is looking for effective ways to meet the budgetary needs while still achieving the patient satisfaction. Table 2 shows the distribution of responses within each category of type of PN. Palliat Med. This study used an embedded mixed-methods approach [44] to explore patients’ expressions of PNs and nurses’ responses to them in a hospice ward in Scotland, which serves both urban and rural populations. Qual Health Res. & Forbat, L. Nurses respond to patients’ psychosocial needs by dealing, ducking, diverting and deferring: an observational study of a hospice ward. Enhancing the therapeutic potential of hospital environments by increasing the personal control and emotional comfort of hospitalized patients. On other occasions disruptions like these, or a patient’s awareness that their PNs were holding the nurse back from her work, could inhibit patients from requesting psychosocial support. Part of Int J Palliat Nurs. These interventions draw techniques from cognitive behavioural therapies (CBT) and educational theories. 2008;22:768–74. Psychosocial intervention is carried out through two interrelated contexts: psychological and social. Qualitative Data Analysis An Expanded Sourcebook: 2nd ed. Many thanks to Strathcarron Hospice and the University of Stirling for financial assistance with this study and publication fees. J Clin Nurs. Conversely, nurses were observed providing holistic care by recognising and responding to patients’ PNs in a way that required much skill. When the nurses focussed on ‘getting their work done’ rather than the patient’s individual needs, they failed to provide the patient with the care they required. All of the PNs outlined in the literature summarised above were expressed at some point during the fieldwork in the hospice. Twenty-three were RGNs, fifteen were AuxNs. During the 8-month period of observation, 227 encounters within 38 episodes of care were observed among 38 nurses and 47 patients. Some of the prior strategies and psychiatric nursing care plans have been suggested below. As a consequence, staff were reluctant to offer Andrea’s parents anything other than superficial information. The suggestion was made that Vera’s respite should be extended for both her and her husband’s sake, although she wished to return home on the originally planned day of discharge. Chapter 25: Ethnographic interviewing. ‘Identity’: The need for patients to have feelings of self-worth and to sustain relationships where possible. When Stuart, the HCP, and Camille were talking, Stuart mentioned ‘when I’m up walking’. Nurses ‘deferred’ psychosocial support either because they felt they did not know enough about the patient and/or their PN or because they felt it was another staff member’s role to deal with the need. The following case study outlines how staff overcame perceived and actual service obstacles to engage one client and her family using PSI. The data included in this paper, and the discussions around the observed care, provides nurses everywhere with an example against which to compare their own practice. Nina felt she had “never had any training in psychosocial care”. Costello J. 3rd ed. These PNs were not discussed with Bruce during any observations. Int J Nurs Stud. However, despite this idea being repeated by the nurses - 37 of the 38 participating stated this claim – the idea that familiarity is required to provide psychosocial support was unproven [60]. 2010;17:278–89. The specialist palliative care nurse: a qualitative study of the patients' perspective. She had deteriorated shortly after her admission, but was back to her normal state of health by the time of the multi-disciplinary team meeting (MDTM). However, the general consensus among the MDTM was that Vera’s admission should be prolonged. Placation was a common response when nurses felt they required more information before a patient’s PN could be dealt with. In: Atkinson P, Coffey A, Delamont S, Lofland J, Lofland L, editors. 2011;18:111–22. Cite this article. Later Julie said ‘I didn’t want to disturb you to say we were away for our tea, ‘cause I could see you were in something deep’. An embedded mixed-methods study was conducted in one hospice ward. This enabled Andrea’s nurse to present formal data to the care team and influence the decision to reduce her medication levels, as well as change staff attitudes. Hazel: “With Polly yesterday, when you had her in the hoist, how did you feel about how she was?”, Sybil: “Well she wasn’t comfortable. 2011;17:245–50. Dale M, Johnston B. 2007;21:32–40. She was also depressed and experiencing some paranoid thoughts - but her paranoid symptoms did not rate as highly as the staff had previously perceived. At another point later in the conversation Rhona, the nurse in charge of the team this morning, shouted ‘Hazel, we’re away for tea, here’s the keys’. The stress vulnerability model (Zubin and Spring, 1977) was explained to Andrea and her family. In the past Andrea had had negative experiences of psychiatric treatment and inpatient services. The potential of incorrectly recording observations was reduced by the collection of other data, especially matched interviews, carried out as soon as possible after the care, with the patients and nurses involved and about their interaction. One example of this occurred during an episode of care with Vera, a patient who had been admitted to the ward for one week’s respite. 2006;54:594–601. The nurse focussed on what the patient wanted, thereby meeting a number of PNs, including autonomy and a sense of belonging. Palliat Med. ‘Deferring’ encounters left the nurse with two options. The researcher then introduced herself to all ward patients. After a short pause Ann suggested to him ‘but you're quite happy here, aren't you?’ and he said ‘yeah, so I'll stay here, today.’. Ellen’s suggestion to use the wheelchair, and the way it was put to Wendy, had positive impacts on Wendy’s psychosocial well-being. However, instead of doing this, Marguerite (RGN) offered what she thought would be a quick solution to Eliza’s problem and Lily (RGN), facilitated this offer: “[Eliza’s] fed up with 4 walls, missing getting out of the room, [query] consider change of environment, move to [another room] would mean she could have patio doors open.” Marguerite. Within these encounters, 330 PNs were expressed. One reason nurses attribute to lack of dealing with PNs, especially those relating to emotional expression, is ‘not knowing a patient’ [58, 59]. 2004;14:816–35. The supportive care needs of men with advanced prostate cancer. The five nurses who did not offer to participate were all AuxNs. Potter PA, Perry AG, Stockert PA, Hall A. Essentials for nursing practice: 7th ed. Clinical Standards Board for Scotland: Clinical standards: Specialist palliative care. However, when she was settled into the chair Eve’s mood changed and she sombrely said ‘you know, I was up and walking when I first came in here and now I can’t.’ Nina made no response to this. Low staffing levels hampered nurses’ attempts to establish a relationship with her. Copp G. Facing Impending Death Experiences of Patients and Their Nurses. Bergdahl E, Benzein E, Ternestedt B, Elmberger E, Andershed B. Co-creating possibilities for patients in palliative care to reach vital goals - a multiple case study of home-care nursing encounters. Privacy For example, one patient Eliza liked to keep busy. 2003;7:120–9. This usually happened because nurses felt there was pressure on them that ‘they must complete a set of duties during their shift’. Nursing interventions are activities or actions that a nurse performs to achieve client goals. Confidentiality was maintained by the use of pseudonyms and ensuring any potentially identifying details were removed from all data. This situation occurred when Julie (AuxN) had assisted Teresa with a shower and to return to her bedside, where the doctor then attended to her: When the doctor left, I went behind the screens to put Teresa’s Lidocaine patch on. Thus Ellen’s intuitive actions dealt with Wendy’s PNs. Olthuis G, Dekkers W, Leget C, Vogelaar P. The caring relationship in hospice care: an analysis based on the ethics of caring conversation. Evie paused for a wee while, then replied ‘oh, that's right, we must chase that up. London: SAGE; 2009. The World Health Organisation: WHO definition of palliative care. According to type of PN health, and expression dealt with, paranoid and was irritable whenever was... And expression and functions of the ordinary: 'being-with ' in the social behavioural! Had deteriorated ‘ diverting ’ encounters the nurses ’ responses were when a patient ’ s stay he had many! 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