Background
The evaluation conducted in France by la Direction Générale de l’Offre de Soins (Directorate of Health Care Supply) of the plan from 2008 to 2012 and the report concerning Palliative Care [
1] underscored the primary mission of the Mobile Palliative Care Teams (MPCT): the implementation of a Palliative Approach (PA) by care-givers within hospital care units. In France, a MPCT is a multidisciplinary team (nurses, physicians, psychologist …) within a hospital which offers a consultation service to other care units. Its members do not provide directly patients care but advise and support teams.
The report of the Commission on End-of-Life in France found “an inability of specialists to engage in a PA within their units. It showed that 80% of physicians had never been specifically trained” [
2]. The American Society of Clinical Oncology recommending the early merging of standard care and palliative care, found a gap between recommendations and practices [
3]. An American study which evaluated current hospital-based palliative care programs using the recommendations from the Center to Advance Palliative Care in seven hospitals [
4], identified several barriers: limitations in palliative care skills, the understanding of the patient’s social and spiritual concerns and overall communication among a team of care providers, which emphasize the need to expand educational and training programs. A Canadian Society of Cancer report noted that the use of palliative care services by medical caregivers remained low [
5]. In 2012, one third of oncologists sent their terminal cancer patients to a palliative care service in Canada; while in within the region of Paris, only 3 oncologists out of 150 were trained in palliative care [
2].
However, a number of studies showed that the early application of a PA provide beneficial results for patients with cancer: better quality of life, less depression, less hospitalisations and higher rate of survival [
6,
7]. If the interest of palliative care has not yet been discussed, why is there reluctance in implementing it early on? An Italian study with 283 nurses working in medical, surgical and intensive-care units, showed that the nurses who were given the necessary room to provide the best care they could deliver exhibited less cases of burn-out and development of strategies to improve nurse satisfaction in working were recommended [
8]. Another qualitative study on the causes of nurses stress identified high workloads, unavailability of physicians, unsupportive management and interpersonal issues [
9].
In 2016, the MPCT from the Montpellier’s CHU took on 608 palliative care patients (2266 interventions within 58 medical and surgery care-units for adults) and delivered 1053 h of basic and follow-up training for the caregivers [
10]. Despite positive feedback from caregiver teams, MPCT nurses reported difficulties by nurses in the care-units in grasping palliative care and replicating what they had learned from their training. One Swiss phenomenological study about the utility of MPCT showed difficulties in initiating a partnership, the nurses preferring to delegate complex care to the nurse of the MPCT [
11]. A Belgian study defined caregiver resistance in implementing a PA as “the unconscious refusal to put attitudes or learned actions into practice when faced with a patient in need of palliative care” and identified six factors: feelings of powerlessness, the lack of training, the need to protect oneself from stress, personal beliefs and the quality of social and organizational support [
12]. A French study showed that in spite of a 5-year training program, the implementation of a PA was tardy; 49% of nurses feared that the use of a PA would cause anxiety in the patient and 90% found it difficult to choose the right moment [
13]. A cross-sectional Survey of 363 nurses in a multispecialty hospital showed that overall level of nurses’ knowledge about palliative care was poor [
14]. For Gamblin et al. [
15] the resistance of the caregivers came from a discrepancy between a normative ideal and the actual reality.
In Norway, nursing homes and home-care managers requested the mobile teaching team’s service for supervision for caregivers who felt anxious. Expert nurses helped be more secure and confident when faced with situations of bereavement and were able to guide nurses of care-units althrough the complexities of practice within «workplace learning » [
16].
The diverse data poses numerous questions: Why do nurses encounter reluctance to the implementation of palliative care despite its effectiveness? Are these difficulties psychological, organizational, and/or managerial? How can MPCTs help them?
Methods
Aim
The objective of the work initiated by Montpellier’s MPCT was to understand the PA of the nurses in the medical and surgical care-units of 3 hospitals in the South of France and the circumstances and impact of the use of MPCTs, using a phenomenological approach focused on the lived experience.
Design
A qualitative phenomenological study was chosen to describe and understand the experiences of nurses within complex PC situations. This report were guided by COREQ [
17].
Recruitment and characteristics of participants
A letter was distributed by the health services to Registered Nurses (RN) facing palliative care, informing them of the research and of the upcoming study. The nurses were recruited from the medical and surgical care units in three different locations in the south of France, on a voluntary basis through authorization from the head of healthcare: CHU of Montpellier, CHU of Nîmes, and the hospital of Sète. Patients with both curative and palliative needs were cared for on these wards. We used purposive sampling to obtain a diversity of nurses’ experiences across various characteristics such as age, sex, the type of health service, years of practice and specific training. We applied the principle of data saturation without pre-defining the number of interviews.
Data collection
The first collection method comprised of phenomenological interviewing that took place in person, to understand the experience in depth. The second took the form of focus groups, to look at the interaction between participants and their common experiences. An interview guide (Table
1) including open-ended phenomenological questioning focused on lived experience was developed. Two qualitative research methodologists verified the appropriateness, as well as the intelligibility of the questions, after the two initial test sessions were conducted with nurses. Follow-up prompts were designed to lead participants to recount their personal experience. The same guide was used for the focus group. The three interviewers (MPCT nurses) received preliminary training on phenomenological reformulation in order to carry out in-depth interviews. An experienced moderator (qualitative methodologist) facilitated the focus groups. Participant characteristics were noted and the conditions surrounding the interviews was taken into account for the analysis: the time, place, position of those involved and context. The interviewer introduced himself as a researcher working in the field of palliative care. The interviews were recorded with a TASCAM Dr-100MKII digital recorder. The sound quality was tested and deemed sufficient quality for recording. The interviewer made sure to create an atmosphere of confidence so that responses would be spontaneous. The recordings were transcribed verbatim by two secretaries. Each received a number in order to remain anonymous. We did not plan to collect non-verbal data.
In a few words, what does palliative care mean to you? |
I In the healthcare service where you encounter palliative care: How would you say it goes in general? What happens? |
Follow-up: What would you say is the place of primary care nurses within the context of PC? How do you imagine it? Are you satisfied? Do you like your role? What does a palliative approach mean to you? |
II Do you remember the last patient that you had who went through palliative care with you: Describe the situation. Think about the day, the place and who you were with. What happened? What were your thoughts at the moment? What did you do? |
Follow-up: Do you remember what you experienced in the situation? What thoughts came into your mind? What did you do and why? Which problems did you need to solve? What did you have at your disposal from your personal experience that helped you? (see if she makes reference to experience, professional values, knowledge, techniques, biographical lived events, other colleagues? Which other colleagues?) Did you feel that you had a particular need in that moment or that you were lacking anything? If so, did it cause you to suffer in any way? What did you take from this experience? |
III With regards to this personal experience that you have just spoken about: The litterature says that despite a solid knowledge of palliative care by healthcare workers, patients do not always benefit from a palliative approach. What do you think about that? How would you judge the partnership with MPCT? With the nurses in the MPCT? |
Follow-up: In what ways specifically do you see this collaboration? Do you think this collaboration is possible? Can you tell me if you have found difficulties in this partnership? What are they? Have you had an experience where a palliative approach was not implemented? Do you remember your thoughts or emotions at that moment? Do you recall a situation where a palliative approach was put into place? (wait for the answer before asking the second part of the question) Did you experience a particular feeling? What was it? Did you feel enriched? In what way? |
IV In light of everything that you’ve said so far, what could shared care meanfor you? |
Follow-up: Would you be able to integrate this idea into your daily practice? |
Do you have anything to add? |
Data analysis
Semiopragmatic Phenomenology is a descriptive method for categorizing lived experience recorded in interview transcripts. The first steps of this analysis (Table
2) were performed according to a constant comparison process [
18] to build the categories, completed by a semiopragmatical data interpretation procedure inspired by C.S. Peirce [
19]. In this method, the analyst takes into account all the semiotic elements of a text, including linguistic and contextual clues. First, empirical categories emerge by constant comparison. Secondly semiopragmatical analysis allowed the logical ordering of these empirical categories according to Peirce’s theory of signs [
20,
21]. Typically, as a result of this ordering, the conceptually densest category (i.e., of the highest level in the hierarchy of signs) commanded the meaning of the phenomenon at play. The same analysis method was used for the different methods of data collection.
Table 2
Semiopragmatic Analysis Steps according to Peirce’s theories
Accurate transcription of the recordings (French: verbatims). |
Identifying the most relevant elements of the preexisting context. |
General intuitive reading, followed by targeted reading. |
Dividing text into meaning chunks and then into the first themes. |
Identifying all indexical, textual and contextual signifiers (indices) for a first categorization. |
Categories increase in level of generalization through constant comparison |
Arranging those categories according to their logical inter-relationships. |
Constructing the meaning of an emerging phenomenon via a general proposition. Meaning organization though logical ordering according to the hierarchy of signs |
Ethics approval and consent to participate
Participants signed an informed consent form. The respondents were informed that their responses would remain confidential and anonymous as they their name would not be aggregated with their personal identification details. They were also informed that they could stop participating in the study at any point.
We asked the privacy and compliance officer of the university hospital of Montpellier for a IRB review. Since no data were collected regarding the participants health statuses, there was no obligation to seek approval from an ethical committee in France. However, the university hospital of Montpellier recorded the material in accordance with all french ethical regulations (ref: MR-003).
Discussion
Our study clarified our objective to understand the palliative approach of RN in hospital care units and how they make use of the MPCT.
Nurses recognize their role as being witnesses to the patient’s experience through their constant presence which is in line with their professional values. In turn, this gives them an “alert role” that can help in anticipating and preparing for a patient centered palliative approach, in accordance with recent results published by Schroeder & Lorenz [
22].
However, in reality, it is the physician’s positioning and his/her attitude toward a palliative approach that sets the tone for its implementation and determines the behavior of different staff members within the healthcare service. According to RNs, when physicians remain anchored in a curative paradigm, there is a risk of not recognizing nurse’s individual role and delaying access to palliative approach. However, Fox et al. [
23] pointed to “becoming palliative” is not a defined event; as such, ambiguity and tension contribute to the difficulties involved in negotiating the transition to palliative care. Failure to recognize RN’s role can distort professional values, lead to suffering, inappropriate behavior, or even certain infringement of the rules. Moreno-Milan et al. [
24] brought to light the concept of “meaning of work” as a support to personal protective factors (self esteem) and identity values and decreasing perceived stress. This entails striking a balance between the feeling of being inadequate/dissatisfied and adequate/satisfied with one’s work [
25]. Studies concerning district nurse’s experiences of palliative care in the home revealed that they experienced a feeling of professional inadequacy [
26]. In a recent scoping review, half of the 25 included studies provided possible outcomes of “bad deaths” such as palliative care not being initiated, interpersonal and team conflict [
27]. The benefit of this work is to put forward the core category “the recognition of the individual role of the RN” as an essential concept for understanding what causes the delay in the implementation of a PA. This confirms the findings of Reimer-Kirkham et al. [
28] and Hahne et al. [
29]: the perceived differences in knowledge and skill among team members and a perceived absence of fairness negatively influenced overall cohesion and confidence. Although recognizing a pivotal role of RN in end-of- life care allows to shift from the model of the physician alone deciding to an approach where nurses also shared responsibility [
30], several international studies found that the profession is not granted sufficient recognition and legitimacy as shown by Sekse et al. [
31]. While physicians planned the care, the nurses, who spent the most time with, and knew the patients the best, were not involved in the planning [
32]. Physicians did not listen to the nurses and did not want to prescribe in accordance with their advice [
33]. Findings concerning nurses’ role from Hospice in the USA demonstrated poor collaboration with the physicians [
34].
Although worldwide training on palliative care for health professionnals is often limited [
35], interprofessional training (physicians and nurses) could optimize sharing expertise [
36]. This is in line with the 76th World Health Assembly focusing on strengthening palliative care [
37] and a recent study showed how nursing homes can become useful sites for learning about end-of-life care during internships [
38]. A collective training program (undergraduate and postgraduate) for medical and nurse students would give an opportunity to learn from and about each other, which facilitate this recognition of each person’s skills as well as a clarification of the individual role.
The hypothesis that the questioning of RN professional values limiting his/her capacity to become involved in palliative care could explain the results of the work that highlight the reluctance despite training [
15,
16] or those showing difficulties in partnering with a MPCT [
10]. In contrast to what the palliative care nurses reported about their interventions at CHU of Montpellier, those in our study indicated a need for the use of MPCTs and their important contribution on a personal and professional level. They considered them as a “facilitating intermediary” within the healthcare service restoring a “balance” in the communication and in decision-making between physicians and other care workers, leading care teams to an anticipated and patient-centered palliative approach with regards to roles and skills according to guidelines. It is possible that for the RNs in our sample, the interventions from the MPCTs helped them recover their professional values as nurses and diminish the reluctance.
Strengths and weaknesses of the study
This work hypothesized an internal methodological consistency between the object of research (lived experience), the data collection methods, and the data analysis favouring a logic of emergence. In each step of the process, there was transparency.
Regarding the data collection, the nurses of the MPCT that conducted the interviews were known by most of the participants in the study. This may introduces a bias. However, at the same time, this also allows for an environment of confidence and authenticity in the responses. It was difficult to find times when nurses were available because the interviews happened during work hours and it was necessary to get approval from the administrators and physicians in their area.
Most of the nurses interviewed were young (n = 15 less than 40 yo) with little to no training in palliative care (n = 14 less than 3 days training). Regarding the situation in France, hospital nurses are younger than non-hospital and freelance nurses. This may be a consequence of legislation requiring newly graduated nurses to practice under the authority of a head nurse. One hypothesis could be that an activity primarily focused on curative care in these care units does not make palliative care training a priority. The interviews were stopped upon reaching data saturation. The triangulation of methods of data collection (individual interviews and focus group), as well as the triangulation of analysts (5 researchers discussing their results) permitted for more nuanced information and brought validity to the results. The individual interviews gave personal and private information about the feelings of the nurses. The focus group generated information focused on their professional position, medical power and the common feeling of lack of recognition. Additionally, the focus group carry out the opposing positions of the two paradigms: that of the nurses, which is more focused on care and that of the physicians, which is more directed toward the cure. A similar study on physicians is in its final stages, would nuance this results.
The originality of this semiopragmatical analysis is that it is the only one allowing a logical ordering of categories.
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