Cancer has been the major cause of death in Japanese population since 1981 with one third of people dying from cancer from 2005(Ministry of Health, Labor and Welfare, 2012). Basic Law for Anticancer Act was enacted in Japan in 2006 and promotion of home healthcare was commenced (Ministry of Health, Labor and Welfare, 2007). More than half of Japanese people wish to spend the terminal phase of their illness at home but the actual rate of home death is about 10% of the population (Cabinet Office, Government of Japan, 2012). In case of cancer, it is about 8% (Japan Hospice Palliative Care Foundation, 2013). To realize the patient’s wish of going home and dying at home, home visiting nurses need to relieve patient’s pain, ease the burden on family caregivers, manage daily life including individual needs and requests, provide emotional support to the dying and family, and also allow patients to discuss their spiritual issues. It is important for visiting nurses to realize the spiritual pain of patients, determine its causes and triggers, select an appropriate intervention to improve spiritual care.
Purpose: This study aimed to explore the spiritual care process of home visiting nurses for patients in terminal phase of advanced cancer.
Methods: Semi-structured interviews were conducted with eight registered nurses who had experience as a home visiting nurse for over three years in end-of-life care. The interview contents included: priorities that nurses valued in their end-of-life care, and how they assess and intervene with patient’s spiritual needs. Data were collected from August to September 2016, and analyzed by modified grounded theory approach (M-GTA; Kinoshita, 2003; 2014). This approach was developed by adopting the theoretical and content properties of the grounded theory approach (GTA; Glaser, Strauss & Strutzel, 1968), and then adding some modifications. M-GTA was judged to be suitable for this study because its aim was to develop a theory of spiritual care process.
Results: As a consequence of analysis, one core category and two sub categories were extracted. The core category was: clinical reasoning to clarify spiritual pain and consisted of sub categories:ⅰ)end-of-life total care, ⅱ) achieving spiritual care”. Home visiting nurses provided spiritual care based on “end-of-life total care” with 6 concepts of care including being: polite, patient-centered, without pain, aware of family distress, management of daily activities, in order to allow patients to remain at home. The process continues with clarifying the patient’s spiritual pain through clinical reasoning. This clinical reasoning of “end-of-life total care” and “achieving spiritual care” consised of 8 concepts: understanding patient’s predicted path to death, accepting the patient’s worries, and searching for common ground, questioning and searching repeatedly, deciding to withhold intervention, being prepared to consider timing of intervention , and intervening as a keyperson. After the patient’s death, some home visiting nurses realized the patient’s spiritual pain and learnt from others by team debriefing concerning achieving spiritual care.
Discussion: This study revealed home visiting nurse’s spiritual care process based on end-of-life total care, providing spiritual care, clarifying spiritual pain through clinical reasoning. The process of achieving spiritual care was closely related to the nursing process which consists of assessment and diagnosis, planning, intervention, evaluation. Nurses should provide appropriate spiritual care using nursing process and clinical reasoning (Caldeira et al., 2017).In this study, understanding patient’s predicted path to death, accepting the patient’s worries, searching for common ground, questioning and searching repeatedly on “end-of-life total care” belongs to assessment and diagnosis. Deciding to withhold intervention, being prepared to consider intervention time belongs to planning, intervening as a keyperson are included in the intervention. Debriefing on end-of-total care is necessary for home visiting nurses, which is applicable as an evaluation. Team collaborating with referral for relatives / carers to appropriate debriefing is recommended (Osono et al., 2014). Access to a home-based program for end-of-life care increased the possibility of dying at home when compared to usual care (Shepperd et al., 2016), this could include appropriate spiritual care.
Conclusion: This study revealed home visiting nurses provide spiritual care based on end-of-life total care and the care process was created by clinical reasoning. Home visiting nurses need opportunities for learning about clinical reasoning concerning spiritual pain to achieve end of life spiritual care. Future research recommendations include the development of a questionnaire which can test this model of care and compare home visiting nurses with hospital based nurses in total end-of-life care, both nationally and internationally.