Clinical Nurses' Perceived or Experienced Obstacles and Supportive Behaviors in Providing Care for Terminally Ill Cancer Patients

Kyung Suk Heo; Eun-Jun Park

doi:10.5388/aon.2016.16.3.147

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Heo and Park: Clinical Nurses' Perceived or Experienced Obstacles and Supportive Behaviors in Providing Care for Terminally Ill Cancer Patients

Original Article

Asian Oncology Nursing 2016; 16(3): 147-157.

Published online: 30 September 2016

DOI: https://doi.org/10.5388/aon.2016.16.3.147

Clinical Nurses' Perceived or Experienced Obstacles and Supportive Behaviors in Providing Care for Terminally Ill Cancer Patients

Kyung Suk Heo¹, Eun-Jun Park²

¹Konkuk University Chungju Hospital, Chungju, Korea.

²Department of Nursing, Konkuk University, Chungju, Korea.

Address reprint requests to: Park, Eun-Jun. Department of Nursing, Konkuk University, 268 Chungwondaero, Chungju-si Chungcheongbuk-do, 27478, Korea. Tel: +82-43-840-3953, Fax: +82-43-840-3958, eunjunp@kku.ac.kr

Received 12 September 2016 Revised 28 September 2016 Accepted 28 September 2016

(open-access):

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

The purpose of this study was to examine obstacles and supportive behaviors perceived or experienced by clinical nurses providing care for terminally ill cancer patients.

Methods

Beckstrand's survey questionnaire was translated into Korean and verified by an expert committee and through a preliminary study. A survey that used 26 questionnaire items on obstacles and 24 on supportive behaviors, was conducted among 228 registered nurses with more than one year of experience at medical-surgical general wards in a hospital.

Results

The highly-perceived and frequently-experienced obstacles in providing care for terminally-ill cancer patients were related to patients' uncontrollable pain or psychologically unstable family members. The highly-perceived and frequently-experienced supportive behaviors were related to caring family members or having supportive family members. However, nurses' perceptions or experiences of multiple obstacles and supportive behaviors differed by hospital type, career length, and department.

Conclusion

Nurses seem to be in need of training for pain management for terminal cancer patients and of family care in general. Highlyperceived and highly-experienced obstacles or highly-perceived but rarely-experienced supportive behaviors should be intervened without delay considering a hospital type or nurses' career length.

Keywords: Nurses, Terminally Ill, Neoplasms, Terminal Care, Surveys and Questionnaires

Figures and Tables

Table 1

General Characteristics of Study Participants (N=228)

Characteristics	Categories	n (%) or M±SD
Gender	Male	3 (1.3)
Gender	Female	225 (98.7)
Age (year)		30.07±6.57
	≤25	38 (16.7)
	26~30	99 (43.4)
	31~35	39 (17.1)
	≥36	52 (22.8)
Education	Associate	105 (46.1)
	Bachelor	113 (49.6)
	Master	10 (4.3)
Hospital type	Tertiary care hospital	96 (42.1)
	General hospital	109 (47.8)
	Long-term care hospital	23 (10.1)
Department	Gastroenterology	39 (17.1)
	Oncology	28 (12.3)
	Pulmonology	34 (14.9)
	General Surgery	50 (21.9)
	Others	77 (33.8)
Career years		6.92±5.08
	<5	106 (46.5)
	≥5~<10	67 (29.4)
	≥10	55 (24.1)
Number of patients per duty		17.73±7.73
	<10	26 (11.4)
	≥10~<20	99 (43.4)
	≥20~29	103 (45.2)
Number of terminally-ill cancer patients (monthly)	<5	154 (67.6)
	≥5~<10	53 (23.2)
	≥10~<15	10 (4.4)
	≥15	11 (4.8)

Table 2

Perception & Experience of Obstacles in Providing Care for Terminally-Ill Cancer Patients (N=228)

Obstacles	Perception (Intensity)		Experience (Frequency)
Obstacles	M±SD	Rank	M±SD	Rank
1. Patients having pain that is difficult to control/alleviate	3.79±0.95	1	3.13±1.07	1
2. The nurse having to deal with angry family members	3.76±1.11	2	3.01±1.15	3
3. The nurse having to deal with distraught family members while still providing care for the patient	3.68±1.09	3	2.89±1.04	7
4. Families and friends who continually call the nurse wanting an update on patients' condition rather than calling the designated family member for information	3.64±1.22	4	2.93±1.21	5
5. Poor design of units that do not allow for privacy of dying patients or grieving family members	3.54±1.20	5	2.77±1.31	8
6. Dealing with anxious family members	3.53±1.00	6	3.04±1.02	2
7. Family members not understanding the consequences of continuing aggressive treatments (e.g. chemotherapy-induced nausea, diarrhea, and anemia)	3.52±0.95	7	2.70±1.10	11
8. Not enough time to provide quality end-of-life care because nurses are consumed with activities that are trying to save patients' lives	3.50±1.16	8	2.93±1.20	6
9. Being called away from patients and families to help with a new admit or to help other nurses care for their patients	3.50±1.06	9	2.95±1.16	4
10. Continuing treatments for dying patients even though the treatments cause patients pain or discomfort	3.50±1.14	10	2.43±1.13	15
11. Lack of education and training regarding end-of-life care and family grieving	3.36±1.04	11	2.50±1.05	12
12. Patient having too many visitor	3.34±1.10	12	2.77±1.10	9
13. Intrafamily fighting about whether to continue or stop aggressive treatment	3.30±1.13	13	2.43±0.98	14
14. Employing life-sustaining measures at families' requests even though patients signed advanced directives requesting no such treatment	3.28±1.24	14	2.10±1.23	18
15. Not really knowing what to say to grieving patients or their families	3.25±1.03	15	2.45±1.05	13
16. Families, for whatever reason, are not with patients when they die	3.23±1.21	16	2.02±1.04	21
17. Families not accepting what the physician tells them about patients' poor prognosis	3.20±1.07	17	2.39±0.81	16
18. Nurses knowing about patients' poor prognosis before families are told the prognosis	3.18±1.19	18	2.75±1.05	10
19. Physicians who insist on aggressive care until patients are actively dying	3.15±1.20	19	2.29±1.07	17
20. Pressure to limit family grieving after patients die to accommodate a new admit to that room	3.00±1.37	20	1.97±1.25	22
21. Families being overly optimistic despite patients' poor prognosis	2.94±1.16	21	2.03±0.97	20
22. Patients' families not wanting patients to be overly sedated because of too many pain medication doses	2.89±1.19	22	1.97±0.92	23
23. No available support person for families such as a social worker or religious leader	2.86±1.18	23	2.06±1.10	19
24. Physicians who are overly optimistic to patients and families about patients surviving	2.82±1.25	24	1.93±0.96	24
25. Dealing with cultural differences families employ in grieving for dying family members	2.67±1.15	25	1.68±1.05	25
26. Unit visiting hours that are too restrictive	2.21±1.42	26	1.67±1.20	26

Table 3

Intensity, Frequency for Supportive Behaviors in Providing Care for Terminally Ill Cancer Patients (N=228)

Supportive behaviors	Perception (Intensity)		Experience (Frequency)
Supportive behaviors	M±SD	Rank	M±SD	Rank
1. Allowing family members adequate time to be alone with patients after he or she has died	3.90±1.04	1	3.06±1.18	1
2. Having family members accept that patients are dying	3.78±1.07	2	2.70±1.01	3
3. Having the family physically care for dying patients	3.73±1.08	3	2.52±1.03	6
4. Providing a peaceful, dignified bedside scene for family members once the patients has died	3.66±1.05	4	2.60±1.16	4
5. Teaching families how to act around dying patients such as saying to them, "She can still hear, it is okay to talk to her	3.60±1.17	5	2.16±1.12	10
6. Having experienced nurses model end-of-life care for new nurses	3.59±1.22	6	2.10±1.06	11
7. Having family members thank you or in some other way show appreciation for your care of patients who died	3.57±1.05	7	2.25±0.91	8
8. Having one family member be the designated contact person for all other family members regarding patient information	3.56±1.05	8	2.54±1.02	5
9. Having a fellow nurse tell you, "you gave great care to that patient,” or some other words of support after the patient had died	3.50±1.21	9	1.91±0.96	13
10. Having the physicians involved agree about the direction of patients' care	3.49±1.12	10	2.36±0.96	7
11. Having enough time to educate families about their loved ones' expected process of dying	3.47±1.08	11	2.21±0.96	9
12. Allowing families unlimited access to dying patients even if it at times conflicts with nursing care	3.43±1.13	12	2.79±1.09	2
13. That palliative care services are provided in wards that are supported by a medical insurance policy	3.40±1.17	13	1.61±0.98	19
14. Having educational inservice classes on how to talk to and take care of dying patients	3.40±1.31	14	1.37±1.02	23
15. Having social work and or palliative care establish rapport with patient and family before patient is actively dying	3.36±1.18	15	1.79±0.99	16
16. The nurses drawing on their own previous experience in end-of-life care with either patients or family members	3.36±1.35	16	1.89±1.34	14
17. Talking with patients about their feelings and thoughts about dying	3.34±1.17	17	1.66±1.01	18
18. Having the physician meet in person with the families after patients die to offer support	3.31±1.26	18	1.46±1.05	21
19. A unit designed so that families have a place to go to grieve in private away from patients' rooms	3.23±1.40	19	1.39±1.28	22
20. Having social work or palliative care as part of the patient care team	3.21±1.22	20	1.56±1.02	20
21.Having fellow nurses put their arms around you, hug you, pat you on the back, or give some other kind of brief physical support after patients died	3.20±1.21	21	1.71±1.10	17
22. Having a support person outside of the work setting who will listen to you after the death of your patient	3.18±1.32	22	1.88±1.27	15
23. Having fellow nurses take care of other patients while you get away from the unit for a few moments after the death of your patients	3.14±1.15	23	1.95±1.22	12
24. Having a unit schedule that allows for continuity of care for dying patients by the same nurses	2.75±1.50	24	1.16±1.11	24

Table 4

Differences of Obstacles in Providing Care for Terminally Ill Cancer Patients by General Characteristics (N=228)

Items		Hospital type (M±SD)			F (p)
Items		Tertiary^a	General^b	LTC^c	F (p)
5. Poor design of units that do not allow for privacy of dying patients or grieving family members	E	2.81±1.25	2.86±1.36	2.13±1.14	3.11 (.047)	a, b>c
8. Not enough time to provide quality end-of -life care because nurses are consumed with activities that are trying to save patients' lives	P	3.76±1.01	3.39±1.23	3.00±1.20	5.20 (.006)	a>c
	E	3.20±1.16	2.80±1.20	2.43±1.16	5.16 (.006)	a>c
9. Being called away from patients and families to help with a new admit or to help other nurses care for their patients	E	2.97±1.19	3.10±1.08	2.13±1.10	7.03 (.001)	a, b>c
10. Continuing treatments for dying patients even though the treatments cause patients pain or discomfort	E	2.59±1.15	2.40±1.12	1.87±0.92	3.93 (.021)	a>c
11. Lack of education and training regarding end-of-life care and family grieving	E	2.61±1.06	2.51±1.03	2.00±1.00	3.24 (.041)	a>c
13. Intrafamily fighting about whether to continue or stop aggres sive treatment	E	2.26±0.90	2.51±1.01	2.78±1.08	3.32 (.038)	a<c
15. Not really knowing what to say to grieving patients or their families	E	2.52±1.01	2.52±1.10	1.83±0.71	4.68 (.010)	a, b>c
20. Pressure to limit family grieving after patients die to accom modate a new admit to that room	E	2.08±1.09	2.08±1.38	1.00±0.73	8.22 (<.001)	a, b>c
24. Physicians who are overly optimistic to patients and families about patients surviving	E	2.25±1.05	1.74±0.85	1.48±.059	10.71 (<.001)	a>b, c

Items		Career years (M±SD)			F (p)
Items		<5^a	5≤ <10^b	10≤^c	F (p)
7. Family members not understanding the consequences of continuing aggressive treatments	E	2.48±1.11	2.94±1.05	2.84±1.06	4.22 (.016)	a<b
15. Not really knowing what to say to grieving patients or their families	P	3.48±0.81	3.07±1.07	3.02±1.25	5.17 (.006)	a, b>c
17. Families not accepting what the physician tells them about patients' poor prognosis	E	2.20±0.83	2.52±0.74	2.58±0.78	5.58 (.004)	a<c
19. Physicians who insist on aggressive care until patients are actively dying	E	2.08±1.07	2.36±1.09	2.58±0.95	4.23 (.016)	a<c
23. No available support person for families such as a social worker or religious leader	P	2.76±1.14	2.73±1.27	3.22±1.08	3.34 (.037)	b<c
	E	1.94±1.08	1.94±1.09	2.42±1.10	3.95 (.020)	a, b<c
26. Unit visiting hours that are too restrictive	E	1.55±1.03	1.52±1.24	2.07±1.35	4.28 (.015)	a, b<c

Items		Department (M±SD)		t (p)
Items		Internal medicine	Surgery	t (p)
14. Employing life-sustaining measures at families' requests even though patients signed advanced directives requesting no such treatment	P	3.54±1.08	3.09±1.35	2.54 (.012)
19. Physicians who insist on aggressive care until patients are actively dying	E	2.49±1.08	1.97±1.08	3.24 (.001)

P= Perception; E= Experience; LTC= Long term care.

Table 5

Differences of Supportive Behaviors in Providing Care for Terminally Ill Cancer Patients by General Characteristics (N=228)

Items		Hospital type (M±SD)			F (p)
Items		Tertiarya	Generalb	LTCc	F (p)
9. Having a fellow nurse tell you, "you gave great care to that patient,” or some other words of support after the patient had died	P	3.60±1.17	3.55±1.16	2.87±1.47	3.60 (.029)	a, b>c
23. Having fellow nurses take care of other patients while you get away from the unit for a few moments after the death of your patients	P	3.43±1.11	2.97±1.14	2.78±1.12	5.46 (.005)	a>c
	E	2.24±1.23	1.76±1.20	1.61±1.03	5.02 (.007)	a>c
24. Having a unit schedule that allows for continuity of care for dying patients by the same nurses	E	1.46±1.15	0.98±1.10	0.78±0.60	6.47 (.002)	a>c

Items		Career years (M±SD)			F (p)
Items		<5a	5≤ <10b	10≤c	F (p)
1. Allowing family members adequate time to be alone with patients after he or she has died	E	3.05±1.21	3.33±1.09	2.76±1.17	3.53 (.031)	b>c
6. Having experienced nurses model end-of-life care for new nurses	P	3.83±.97	3.49±1.35	3.24±1.41	4.68 (.010)	a>c
9. Having a fellow nurse tell you, "you gave great care to that patient,” or some other words of support after the patient had died	P	3.74±1.02	3.45±1.29	3.13±1.37	4.77 (.009)	a>c
12. Allowing families unlimited access to dying patients even if it at times conflicts with nursing care	E	2.63±1.19	3.12±1.00	2.67±.90	4.61 (.011)	a, c<b
16. The nurses drawing on their own previous experience in endof- life care with either patients or family members	E	1.67±1.28	1.88±1.39	2.31±1.30	4.22 (.016)	a<c

Items		Department (M±SD)			t (p)
Items		Internal medicine		Surgery	t (p)
19. A unit designed so that families have a place to go to grieve in private away from patients' rooms	E	1.52±1.25		1.08±1.27	2.38 (.018)

P= Perception; E= Experience; LTC= Long term care.

Notes

This manuscript is a revision of the first author's master's thesis from Konkuk University.

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