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Aims and objectives To review literature on nurses’ coping strategies with patient death. Background dealing with the loss of a patient was viewed as one of the most demanding and challenging encounters in clinical practice. Those nurses who are not competent in coping with patient death may be inadequate in supporting dying patients and their family members, and minimize the quality of end-of-life care. To get a broader understanding of how nurses cope with patient death and to develop meaningful and effective interventions, a systematic review which would help underpin the multidimensional approaches is needed. Design A systematic review. Methods Exhaustive searching in ten databases: cinahl plus, embase, medline, amed, psycinfo, proquest health & medical complete, proquest dissertations & theses global, googlescholar, ethos and caresearch. Meta-aggregation was used to synthesise the findings of the included studies. Results This systematic review aggregated ten categories from the sixteen qualitative studies included, and then two synthesised findings were derived: intrinsic resources and extrinsic resources. The intrinsic resources consisted of setting boundaries, reflection, crying, death beliefs, life and work experience, and daily routines and activity. The extrinsic resources were comprised of talking and being heard, spiritual practices, education and programs, and debriefing. Conclusion This systematic review synthesised the findings about what resources nurses use when coping with patient death and made recommendations on future directions. Areas which could be developed to improve deficiencies that nurses had when faced with the losses of their patients were identified. Nurses need more support resources which better assist them in coping with patient death. Relevance to clinical practice The results of this systematic review could provide evidence for nurses’ coping strategies when dealing with patient death, and the recommendations could be employed by nurses to cope with the losses of patients. This article is protected by copyright. All rights reserved.

Background: Studies have indicated that family members or health professionals may not know or predict their older relatives’ or patients’ health preferences. Although advance care planning is encouraged for older people to prepare end-of-life care, it is still challenging. Aim: To understand the experiences and perspectives of older people regarding advance care planning. Design: A systematic review of qualitative studies and meta-synthesis was conducted. Data sources: CINAHL, MEDLINE, EMBASE, and PsycINFO databases were searched. Results: A total of 50 articles were critically appraised and a thematic synthesis was undertaken. Four themes were identified: life versus death, internal versus external, benefits versus burdens, and controlling versus being controlled. The view of life and death influenced older people’s willingness to discuss their future. The characteristics, experiences, health status, family relationship, and available resources also affected their plans of advance care planning. Older people needed to balance the benefits and burdens of advance care planning, and then judge their own ability to make decisions about end-of-life care. Conclusion: Older people’s perspectives and experiences of advance care planning were varied and often conflicted; cultural differences amplified variances among older people. Truthful information, available resources, and family support are needed to enable older people to maintain dignity at the end of life. The views of life and death for older people from different cultures should be compared to assist health professionals to understand older people’s attitudes toward advance care planning, and thus to develop appropriate strategies to promote advance care planning in different cultures.

Starting school is a major milestone in family life, and there is increasing awareness that a child who is ‘ready for school’ when they begin full-time education is more likely to reach their full potential. This is not only in terms of academic achievement, but also social and behavioural skills, which have an impact later in adulthood ( UNICEF, 2012 ). Health visitors' responsibilities include supporting parents to maximise their child's health and development from birth onwards—a complex and challenging remit for which they need to be continually developing engaging strategies and tools ( Department of Health, 2009 ). This article reviews the collaborative development of a school readiness mobile app for Bridgewater Community Foundation NHS Trust. The project won the prestigious 2016 Journal of Health Visiting Award for School Readiness, and the University of Chester was recognised as a key collaborator in this innovative development. The article seeks to inspire health visiting colleagues to search for collaborative partners to address school readiness in an engaging way with parents.

Background Patient death is an emotional and demanding experience for nurses, especially for new graduate nurses who are unprepared to deliver end-of-life care. Understanding new graduate nurses' experience of death and dying will inform the design of training programs and interventions for improvements in the quality of care and support of new graduates. Objective To summarize new graduate nurses' experience with patient death by examining the findings of existing qualitative studies. Design Systematic review methods incorporating meta-synthesis were used. Methods A comprehensive search was conducted in 12 databases from January 1990 to December 2014. All qualitative and mixed-method studies in English and Chinese that explored new graduate nurses' experience of patient death were included. Two independent reviewers selected the studies for inclusion and assessed each study quality. Meta-aggregation was performed to synthesize the findings of the included studies. Results Five primary qualitative studies and one mix-method study met inclusion and quality criteria. Six key themes were identified from the original findings: emotional experiences, facilitating a good death, support for family, inadequacy on end-of-life care issues, personal and professional growth and coping strategies. New graduate nurses expressed a variety of feelings when faced with patient death, but still they tried to facilitate a good death for dying patients and provide support for their families. The nurses benefited from this challenging encounter though they lacked of coping strategies.

Background: Despite the losses experienced by nurses in their role in palliative care, they wish to continue working in this environment. This is described as resilience, which enhances coping in dealing with death and grief. Aim: To explore the nature of nurses' resilience and the way it is developed. Design: A qualitative research design using grounded theory methods was employed. With theoretical sampling, 18 interviews were conducted and theoretical saturation was achieved. Results: Self-nurturing was evident as the way nurses developed resilience, which included knowledge of self, coping adaptively, valuing care and accepting limitations. Discussion: All participants spoke of the characteristics of resilience from the blend of individual responsibility for self and the support provided by others. However, none had educational pathways to build greater resilience. Conclusion: Integrating support and education to foster nurses' resilience is important to enable self-protection, as well as the provision of high quality care.

Summary Background Managing death in the emergency department is a challenge. Emergency nurses are expected to provide care to numerous patient groups in an often fast-paced, life-saving environment. The purpose of this study was to describe the experiences of emergency nurses in providing end-of-life care, which is the care delivered to a patient during the time directly preceding death. Method Data were collected from 25 emergency nurses during three focus group interviews. The interviews were transcribed and analysed using the qualitative techniques of grounded theory. Results Ten categories emerged from the data that described a social process for managing death in the emergency department. The categories were linked via the core category labelled ‘dying in the emergency department is not ideal', which described how the emergency department was an inappropriate place for death to occur. To help manage the influence of the environment on end-of-life care, nurses reported strategies that included moving dying patients out of the emergency department and providing the best care that they could. Conclusion The results of this study highlight nurses' belief that the emergency department was not an appropriate place for death to occur. Despite being frequently exposed to death and dying, the actions and attitudes of emergency nurses implied the need or desire to avoid death in the emergency department.

Aims and objectives. To describe the process that nurses experienced in engaging with families in Malaysian palliative care settings and the challenges they faced. Background. In palliative care settings, nurses and the terminally ill person’s family members interact very closely with each other. It is important for nurses to work with families to ensure that the care of the terminally ill person is optimised. Research design. A qualitative design using grounded theory methods was used to describe how nurses engaged with families and the challenges they faced. Methods. Twenty-two nurses from home care and inpatient palliative care settings across Malaysia participated in this study. Data were collected through seven interviews and eight focus group discussions conducted between 2007–2009. Results. The main problem identified by nurses was the different expectations to patient care with families. The participants used the core process of Engaging with families to resolve these differences and implemented strategies described as Preparing families for palliative care, Modifying care and Staying engaged to promote greater consistency and quality of care. When participants were able to resolve their different expectations with families, these resulted in positive outcomes, described as Harmony. However, negative outcomes of participants not being able to resolve their different expectations with families were Disharmony. Conclusions. This study highlights the importance of engaging and supporting families of the terminally ill as well as providing a guide that may be used by nurses and carers to better respond to families’ needs and concerns. Relevance to clinical practice. The study draws attention to the need for formal palliative care education, inclusive of family care, to enable nurses to provide the terminally ill person and their family effective and appropriate care.

Recruitment of participants from minority cultures is problematic for any type of research; but more particularly for palliative care research however, because of the perceived additional vulnerability of participants who are facing the end of their life. Even though the goal of palliative care is to improve the quality of the remaining life, the processes involving such vulnerable people require careful consideration. This consideration is doubly important when participants come from minority cultures. This study discusses the recruitment difficulties in a study focusing on the palliative care needs of Chinese people in Australia. Despite being part of Australian society for most of its’ colonized history, Chinese people remain a minority culture and place great importance on their particular culture and traditions. Significant recruitment issues were experienced due to language and cultural constraints, including that death and dying are taboo subjects. The access and recruitment processes utili...

Background: Working with terminally ill patients places palliative care and hospice nurses at risk of chronic stress, mental health problems and burnout. Aim: This study investigated the source and level of workplace stress experienced by palliative care nurses in Australia. Methods: Seventy-one palliative care nurses completed a self-report questionnaire based on the Nurse Stress Index and the Nursing Stress Scale. Information was collected about aspects of work-related stress and level of stress. Results: While the overall level of participants’ stress was low, older participants experienced significantly less stress than younger participants. More than 50% of participants experienced 48 of the 53 stressors. The main sources of stress related to ‘death and dying’, ‘workload’ and ‘dealing with patients and relatives’. The two stressors experienced by all participants were ‘watching a patient suffer’ and ‘dealing with patient and family conflict’. Conclusions: These findings have implications for managers, educators and policymakers in relation to adequate nurse-to-patient ratios, education for staff and an evaluation of how palliative care nurses are supported in the workplace. Conflicts of interest: none

Objective:This article is a literature report on grief issues for health care professionals, undertaken to identify Japanese nurses' grief experience when they work in palliative care units. Health care professionals' grief experience and its impact have not been well understood or identified as a significant issue in Japan.Methods:Published articles relating to this study were searched using electronic catalogues such as CINAHL and PsycINFO, books, and research publications. Key words used for the search were “grief,” “palliative care,” “nurse,” “staff support,” and “Japan.” Both English and Japanese were used for the literature search in order to collect information regarding nurses' grief and support systems in Japan and elsewhere. The literature search covered the period 1990–2006 inclusive.Results:This article explores these issues in the literature as preparation for establishing a study that will particularly look at the influence of nurses' grief on the quality of care provided.Significance of results:Consideration of Japanese culture as it relates to death and dying and to nursing culture is a significant part of this work.

Palliative care research is fraught with many difficulties. There are challenges associated with conducting research with vulnerable patients and families, difficulties with obtaining informed consent, and methodological complexities. Thoughtful construction of research protocols may overcome many of these problems. However, researchers may be powerless to overcome the discomfort of members of human research ethics committees (HRECs) who disallow access to palliative care patients and families. The notion of conducting research with this group is often perceived as abhorrent by those who do not practice in palliative care. This is because of a persistent idea that dying people and their families are so burdened by the dying process and so vulnerable to exploitation that they should not be approached to be involved in research. This over-protectiveness regarding palliative care research often distorts the proper gate-keeping role of HRECs and health-care professionals. This article draws on the authors’ experiences of presenting applications to HRECs over the last 20 years. It explores the responsibilities of HRECs, the responsibilities of palliative care researchers and the rights of patients and families. HRECs and health professionals who endeavour to undertake palliative care research are encouraged to reflect and re-examine the role of ethics committees.

Aims and objectives To develop new insights into the phenomenon of clinical nurse/midwifery consultant clinical effectiveness in a tertiary referral hospital. Background International studies identify the pivotal role clinical nurse/midwifery consultants play in patient outcomes. There remains, however, a significant deficit in our knowledge of how these, or other advanced practice nurses and midwives, apply their extensive experience, ontological understandings and tacit knowledge to the enhancement of patient outcomes in complex healthcare environments. Design This study was underpinned by the principles of Heideggerian hermeneutic phenomenology. Methods Recruitment involved expressions of interest distributed hospital-wide to clinical nurse/midwifery consultants. Inclusion criteria specified a minimum of three years’ experience. Fifteen clinical nurse/midwifery consultants, representing a broad range of specialties, were interviewed. Preliminary descriptive analysis of transcribed data was followed by in-depth hermeneutic analysis. Results The findings comprise four themes: walking beside the patient, anticipating the unexpected, pushing through barriers and leading within a complex system. These themes highlight how clinical nurse/midwifery consultants significantly influence pre-existing trajectories of patient care delivery through context-appropriate strategies. Conclusion This study introduces new insights into the meanings advanced practice nurses and midwives develop from their engagements with patients and how these meanings inform clinical decisions. The paper accomplishes this by drawing on Heideggerian philosophical concepts such as ontological understandings, authenticity and care. It also casts light on the participants’ shared understandings of how to synergise expectations within the team. Relevance to clinical practice The significance of this paper lies in the uncovering of ontological understandings and tacit knowledge of how consultant nurses and midwives optimise patient care delivery in challenging situations. The findings indicate, however, that the value of these internationally established roles is yet to be fully realised. The paper concludes by recommending strategies to assist newly appointed clinical nurse/midwifery consultants transition into these demanding autonomous roles.

Objectives:The aim of this study was to explore the type of relationship and the process of developing these relationships between nurses and patients in palliative care units in Japan. The special contribution that culture makes was examined to better understand the intensity of nurses’ grief after the death of their patient.Methods:Thirteen Japanese registered nurses currently practicing in palliative care units were interviewed between July 2006 to June 2009. Theoretical sampling was utilised and the data were analysed using grounded theory methodology. Constant comparison was undertaken during coding processes until data saturation was achieved.Results:Significant cultural influences emerged both in the type of relationship nurses formed with patients and in the way they developed relationships. The type of relationship was termed ‘human-to-human’, meaning truly interpersonal. The cultural values of ‘Uchi (inside) and Soto (outside)’ have particular implications for the relationship. Four actions Being open, Trying to understand, Devoting time and energy, and Applying a primary nurse role, were identified as strategies for nurses to develop such relationships. The quality of this deeply committed encounter with patients caused nurses to grieve following patients’ death.Significance of results:Culture is a major influence upon the reasons, complexities, and impact that lie behind nurses’ behaviours. Attention is needed to support nurses to sustain a fundamental caring quality in their relationships with patients.

Background Palliative care is specialised health care to support people living with a terminal illness and their families. The involvement of volunteers can extend the range of activities offered by palliative care services, particularly for those living in the community. Activities undertaken by palliative care volunteers vary considerably but can be practical, social or emotional in nature. The types of training and support provided to these volunteers are likely to affect the volunteers' effectiveness in their role and influence the quality of care provided to palliative care clients and their families. Training and support can also have considerable resource implications for palliative care organisations, which makes it important to know how to provide this training and support as effectively as possible. Objectives To assess the effects of training and support strategies for palliative care volunteers on palliative care clients and their families, volunteers and service quality. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, 28 April 2014); MEDLINE (1946 to 28 April 2014); EMBASE (1988 to 28 April 2014); PsycINFO (1806 to 28 April 2014); CINAHL (EbscoHOST) (1981 to 28 April 2014); ProQuest Dissertations and Theses (1861 to 28 April 2014). We also searched the Database of Abstracts of Reviews of Effects (DARE, The Cochrane Library); reference lists of relevant studies; and conducted an extensive search for evaluations published in government reports and other grey literature including the CareSearch database (www.caresearch.com.au (September 2004 to February 2012) and websites of relevant organisations, for unpublished and ongoing studies. Selection criteria Randomised controlled trials (RCTs), quasi-randomised controlled trials, controlled before-and-after (CBA) studies and interrupted time series (ITS) studies of all formal training and support programs for palliative care volunteers. Programs or strategies in included studies were classified according to any stated or implied purpose: that is, whether they intended to build skills for the volunteer's role, to enhance their coping, or to maintain service standards. Data collection and analysis Two review authors screened 2614 citations identified through the electronic searches after duplicates were removed. The search of grey literature through websites yielded no additional titles. We identified 28 potentially relevant titles but found no studies eligible for inclusion. Main results We did not find any studies that assessed the effects of training and support strategies for palliative care volunteers that meet our inclusion criteria. The excluded studies suggest that trials in this area are possible. Authors' conclusions The use of palliative care volunteers is likely to continue, but there is an absence of evidence to show how best to train or support them whilst maintaining standards of care for palliative care patients and their families.

There are many challenges facing researchers with projects requiring multicentred ethics approval. Achieving ethical approval at multiple sites, whether statewide or nationally, is a complex and time-consuming experience, compounded by the research process itself, as well as the recruitment of clinical sites and participants. Human ethics and research committees act as research gatekeepers and, as many research activities involve multiple applications and multiple approvals, can considerably delay the commencement of a project. A delay in ethics approval results in delays recruiting staff and participants, delays in the utilization of funding, and in delays regarding the progress and completion of projects. Such problems are additional problems for researchers of vulnerable populations, such as those in mental health or palliative care, where multicentred research is necessary to ensure the validity of the project itself. A current example of work that has required multicentred human ethics and research approval from around Australia is the establishment of the National Register of Antipsychotic Medication in Pregnancy. The guidelines for embarking on such a project with the requirement of multicentred ethical approval are described. Some of the issues, recommendations, and guidelines presented by the authors are taken from their experiences in establishing multicentred research projects.

Home care services have characteristics that are distinctive from other health care settings. Thus, they require different management systems to those traditionally used in institutional settings. Typical management models often require adaptation for home care services in areas such as staffing, education and support. This includes performance appraisal, where traditional models may be inappropriate when clinicians work alone, with little supervision. This article describes an experience of adapting a performance appraisal tool, in order to be more relevant for staff working in home-based care. The project arose from staff frustration with the expectation of management that a tool developed for institutional settings would be appropriate for the home setting. This frustration gave the impetus for developing a successful appraisal system, and because of staff involvement, the model was wholeheartedly embraced. The process of development is discussed, and the model explained, with commentary about its implementation in a home care service.

This paper discusses a small study that was undertaken in a palliative care unit (PCU) to demonstrate reasons for the lengthy patient turnover time after the death of a patient. The study arose from a managerial challenge about the PCU's efficiency in comparison to other settings of care. While Palliative care services in Australia are loosely funded on a per diem rate, casemix funding models for inpatient services in other settings reward efficiency in terms of length of stay (1). The aim of the study was to undertake a post-death survey, from the nursing perspective, of activities and the time required to deliver follow-up care, as required, to the deceased patient and his/her family. Details of the post-death episode for all patients who died in the PCU over two time periods were collected using a newly designed tool. This paper does not argue for the incorporation of post-death nursing work as a measure of efficiency or quality; rather, it is a demonstration of the type of work and the time involved in carrying out post-death work. This nursing work is an essential but hidden and generally unacknowledged element of palliative care and, not surprisingly, there is a dearth of literature describing the role of the nurse in providing care of the family and others after the patient has died. This project has provided important information about the factors that Protract after-death care, and gives some insight into the role of the nurse after a death occurs in a PCU.

Aim. To identify end-of-life (EOL) decision making processes for patients with non-cancer illnesses in a major metropolitan hospital. Methods. A retrospective review using a case study framework of 47 randomly selected patient records over a 6-month period explored issues in EOL care planning. Results. Reviewed charts represented 53% of total deaths in the study period. All patients (aged 66–99) had co-morbid conditions. In 64%, the first record of EOL discussions occurred in the last 24 h of life. Four case groups were identified, ranging from a clear plan developed with patient/family involvement and fully implemented, to no plan with minimal patient/family involvement in decision making. Factors related to clearer EOL care planning according to expressed patient wishes included multiple previous admissions, shorter hospitalisations at EOL, living with a relative and involvement of family in decisions about care. Conclusion. This study has shown that the development and effective implementation of EOL plans is associated with the active involvement of both family members and health professionals. It also draws attention to the risks of delaying EOL discussions until late in the illness trajectory or later in life as well as pointing to challenges in acting on EOL developed outside the hospital environment. What is known about the topic? End of life (EOL) care planning has been widely discussed in some countries but research into outcomes of such programs has produced variable results both in real outcomes for patients and in satisfaction and ease of application for health professionals. Programs of advance care planning have been introduced in some Australian health services but are yet to produce definitive results. What does this paper add? This paper identifies some of the factors that appear to impact on EOL decision making processes in a major Australian metropolitan hospital for patients suffering non-cancer life-limiting illnesses. These data will facilitate the development of more effective EOL care processes in this and other similar healthcare services. What are the implications for practitioners? Clear effective processes for making EOL decisions are likely to result in better outcomes for patients, family members and practitioners. A distinctive cluster of patient circumstances may identify risk for poor advance care planning.

There is compelling evidence in the nursing literature that the workplace is experienced as morally uninhabitable for many nurses and yet the concept of moral habitability remains underdeveloped. An integrative review on moral habitability in nursing was undertaken. The findings reveal that the primary concepts by which nurses write and research aspects of moral habitability are moral climate, moral agency, moral sensitivity and moral distress. It is revealed that nurses in their clinical work experience adversity and moral distress through relational challenges and contextual difficulties that can challenge habitability and inhibit nurses' capacity to provide morally sensitive patient care. The primary concepts identified provide a framework for further development of the concept of moral habitability within nursing practice. The related data within the integrative review also highlights the need for further research into enhancing and sustaining morally habitable workplaces for nurses.

Background: Palliative care in Malaysia developed in the 1990s to improve the quality of life of people with advanced cancer. Like many other countries, Malaysia faces its own challenges in providing palliative care to patients and their families. In Malaysian culture, families play a significant part in providing care to the dying. Connecting with families in patient care is therefore important. This paper reports a focused literature review evaluating studies on the care of the families of terminally ill people in palliative care environments in Malaysia. Method: The search engines CINAHL, Medline, PsyclNFO, and Google Scholar were searched for literature published from January 2000 to April 2010 relating to family care in palliative care environments. Due to a paucity of research on family care in Malaysia, the search was broadened to include relevant studies on family care internationally. Results: Four themes were identified: delivering palliative care in Malaysia, communicating with families, crossing cultural boundaries, and the caring experience of nurses. Conclusion: The studies indicate the importance of the nurse-family interaction in providing optimal and culturally appropriate palliative care. This paper emphasizes the need for research into the nurse's role in family care and for developing a theory appropriate to the Malaysian culture and other countries with cultural diversity.