To identify nursing philosophy supporting clinical judgment of visiting nurses for terminal cancer patients with care at home.
Methods:
The subjects were visiting nurses who belonged to home-visit nursing stations, had more than five-year experience of home-visit nursing, and had the ability to provide effective care for terminal cancer patients with care at home. They were introduced by snowball sampling with the consent for participating in this study.
Based on literature review, we created an interview guide allowing to extract the content of clinical judgment and conducted a face-to-face interview for the subjects about the actual cases requiring clinical judgment. The interviews were audio-recorded with the consent of the subjects, and were transcribed word by word to create a written record. We extracted the content showing nursing philosophy supporting clinical judgment as codes from the written record. The extracted codes of nursing philosophy were analyzed qualitatively and inductively, and were classified into categories and subcategories according to similarity and abstraction level.
In this study, “nursing philosophy” was defined as important things and belief in nursing, or attitude leading to clinical judgment and nurses’ own nursing activities.
For ethical considerations, this study was conducted with the approval of an ethics review committee in our university.
Results:
1) Outline of the subjects and actual cases of clinical judgment for patients spoken by visiting nurses
The subjects were six visiting nurses who had more than eight-year experience of home-visit nursing with the consent for participating in this study, and all of them were the managers of home-visit nursing stations. The visiting nurses spoke the cases of six terminal cancer patients with care at home: five males and one female (range 40s-70s) with lung, colon, pancreatic, or breast cancers. They were diagnosed to live 6 month or less thereafter. Twelve clinical determination cases were mentioned, and half of them (six cases) were for end-of-life care.
2) Nursing philosophy supporting clinical judgment of visiting nurses for terminal cancer patients with care at home
As nursing philosophy supporting clinical determinations of visiting nurses for terminal cancer patients with care at home, 285 codes were divided into 7 categories including 29 subcategories.
The categories are shown in [ ], and subcategories are shown in < > below.
[Face patients and treat them carefully] consists of subcategories of <Respect patients as an individuals>, <Face patients in sincerity>, and <Nursing care meeting needs of patients and their family>, representing the attitude of visiting nurses to face patients.
[Engage with and understand patients] consists of subcategories of <Catch signs from patients>, <Think about the meaning of words and behavior of patients>, <Understand the life history of patients>, <Make clinical judgment with nurses’ own eyes>, and <Consider the background of patients>, representing the value perspective of understanding patients.
[Feel sympathy with patients] consists of subcategories of <Satisfy wishes of patients>, <Understand feelings of patients>, and <Understand feelings of patients and fulfil their wishes>; [Value the remaining lifetime of patients] consists of subcategories of <Give a higher priority to QOL of patients than lifetime extension>, <Notify the estimated remaining lifetime>, <Palliative care is important>, <Make the remaining lifetime fruitful>, and <Support patients to prepare the time to say goodbye to their family>, representing the wishes of visiting nurses to fulfil wishes of patients facing the end of their life, and make the remaining lifetime of patients fruitful.
[Support families of patients] consists of subcategories of <Understand feelings of families of patients>, <Let not families have feelings of regret for end-of-life care>, <Wish families to feel that end-of-life care was good>, and <After-death care is important as a grief care for families of patients>, representing the value perspective focusing on grief care of families who experience loss of loved persons.
[Support decision making of end-of-life care] consists of subcategories of <Let families choose the place for end-of-life care>, <Determine whether end-of-life care at home is possible>, <Understand confusing and nervous feelings>, <Support the decision of patients and their family>, <Confirm the decision of patients and their family>, <Have contact with hospitals in case of changing the place of the end-of-life care>, representing nurses’ attitude to patients and their family. The nurses were trying to proceed with each process of decision making for end-of-life care carefully, understand their confusing and nervous feelings, and support them while preparing in case of changes in decisions.
[Fulfill the roll and mission as visiting nurses] consists of subcategories of <Responsibility for the role as visiting nurses>, <Closely collaborate with other specialists>, and <Ensure the quality of home-visit nursing care>, representing nurses’ attitude as medical professionals at the closest position before death. The nurses felt that they have strong responsibility to make clinical determinations, support patients 24 hours a day, 365 days a year, and express the necessity of collaboration and coordination with other specialists for home care environment.
Conclusion:
The actual cases of clinical judgment for terminal cancer patients with care at home spoken by visiting nurses indicated that there are a variety of nursing philosophy, and each visiting nurse determined nursing care based on individual nursing philosophy.
For [Face patients and treat them carefully] and [Engage with and understand patients], visiting nurses focus on contacting with patients and their families not as nurses, but as individuals with respect, by engaging with and understanding their life and daily life. For [Feel sympathy with patients], [Support families of patients], [Support decision making of end-of-life care], and [Value the remaining lifetime of patients], visiting nurses focus on feeling sympathy with patients facing the end of their life and families who experience loss of loved persons, supporting decision making of end-of-life care, fulfilling wishes of patients, and valuing the remaining lifetime. This seems to be a nursing philosophy focusing on valuing and supporting patients’ personality to “live as he or she is”.
Nagae (2014) reported that end-of-life care is “the nature of nursing care where nurses engage with the life of patients, and link patients’ daily life with their necessary treatment and care”. This study revealed that nursing philosophy of visiting nurses were based of end-of-life care to support patients’ personality to “live as he or she is”.