Challenges Experienced by Italian Nursing Home Staff in End-of-Life Conversations with Family Caregivers during COVID-19 Pandemic: A Qualitative Descriptive Study

Abstract

End-of-life conversations are among the most challenging of all communication scenarios and on the agenda of several healthcare settings, including nursing homes (NHs). They may be also difficult for experienced healthcare professionals (HCPs). This study explores the difficulties experienced by Italian NH staff in end-of-life conversations with family caregivers (FCs) during COVID-19 pandemic to uncover their educational needs. A qualitative descriptive study based on inductive thematic analysis was performed. Twenty-one HCPs across six Italian NHs were interviewed. Four themes described their experiences of end-of-life conversations: (1) communicating with FCs over the overall disease trajectory; (2) managing challenging emotions and situations; (3) establishing a partnership between HCPs and FCs; (4) addressing HCPs’ communication skills needs. HCPs had to face multiple challenging situations that varied across the care period as well as complex emotions such as anxiety, guilt, uncertainty, fear, anger, or suffering, which required tailored answers. COVID-19 pandemic increased FCs’ aggressive behaviors, their distrust, and uncertainty due to visitation restrictions. HCPs had to overcome this by developing a set of strategies, including adoption of an active-listening approach, supportive communication, and explicit acknowledgement of FCs’ emotions. Since communication needs were mostly practical in nature, HCPs valued practical communication training.

Understanding advance care planning in care homes throughout the COVID-19 pandemic: A critical realist review and synthesis

“…Reduced frequency and completeness of care plans was found to lead in some cases to uncertain and reactive decisions being made, even 7 months into the pandemic. 35,39 Similarly, Gonella et al 30 identified that some staff in care homes had difficulty exploring relatives' preferences for care at the end of life due to a lack of detail in the advance care directives.…”

“…34 The reduced face-to-face contact during the pandemic also appeared to take an emotional toll on relatives and surrogates involved in care planning. 30,33,35 Emotions such as denial and shock concerning a loved one's condition (particularly in the case of acute COVID-19 diagnosis) seemed to be triggered by relatives' reduced ability to directly observe changes over time. 30,31 Although synthesis suggests these circumstances can lead to a greater risk of interventional and curative orientated decisions by relatives, 29,30,35 it was found that frequent ongoing involvement of relatives in care planning conversations can help to mitigate these emotions.…”

“…30,31 Although synthesis suggests these circumstances can lead to a greater risk of interventional and curative orientated decisions by relatives, 29,30,35 it was found that frequent ongoing involvement of relatives in care planning conversations can help to mitigate these emotions. 29,30…”

“…Firstly, actions taken to respond to the threat they posed, notably the introduction of social distancing, altered the organisational context for advance care planning. 30,33 Secondly, it was not only residents who were vulnerable to the virus. High levels of staff sickness led to shortages which challenged staff's capacity to fulfil required functions including advance care planning.…”

“…These included engaging in more frequent discussions (treating care planning as ongoing rather than one-off discussions), active listening and spending longer informing relatives on their loved one's condition and being more alert to emotions in the absence of non-verbal communication. 29,30,33,38 Another important response was the sharing or transfer of responsibility to colleagues, such as home managers or nurse practitioners when discussions were perceived as not being effective. 29,30 Referring to colleagues in this way appeared to facilitate an understanding of the importance of collaborative teamwork and togetherness, for example more experienced staff supporting younger or less experienced staff through pandemic conditions.…”