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Learning Objective 1: Describe components of a culture of care.
Learning Objective 2: Describe how nurses can influence the culture of care to positively impact end-of-life care delivery.
Methods: Ethnographic methods were used to examine cultural influences on the delivery of end-of-life care in three specialty clinics serving patients with life-limiting or terminal conditions (including amyotrophic lateral sclerosis, advanced lung cancer, and heart failure). Data consisted of over 450 observations of patient visits, supplemented by interviews with key informants and observations of general clinic milieu. Prolonged immersion in the filed (>12 months) promoted the rigor of the study. Item level analysis and pattern analysis were applied in an iterative analytic process to reveal the shared values and beliefs that influenced care delivery in each distinct setting.
Results: Shared values, based in expectations of the illness trajectory and related care, were evident in each clinic--that is, a distinct culture of care was evident in each setting. Five interdependent, co-occurring spheres of influence were identified as shaping the care delivery system: Role of formal providers, Perception of patient system, Continuum of care across the illness trajectory, Context of the illness experience, Focus of the visit across the illness trajectory. Different constellations of the spheresof influence created distinct models of the dominant care delivery sytem in each clinic, including: Interdisciplinary; Network Cooperative; and Provider Dominant. The models of care delivery varied significantly in addressing end-of-life issues with the patient and informal family caregiver.
Conclusion: The culture of care manifest in a care delivery system is shaped by shared values and beliefs. Varied configurations of five co-occuring components of the culture of care shape distingt models of care delivery. These models influence how end-of-life care is conceived and delivered. Nurses are instrumental in shaping the culture of care and are positioned to change the care delivery system.
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