The Experiences of Nursing Managers in Implementing Palliative Care in Long-Term Care Facilities

Figures & data

Table 1 Table with Codes, Concepts, and Categories

Open Coding	Axial Coding
Code	Concept	Category
Help residents live with more dignity and alleviate their suffering	Limited understanding of palliative care	The opportunity for change
Alleviate the burden on families
Increase the burden on the facility
Did not know the specific ways could implement
Proactively reach out to the hospital palliative care team	Identified a need for palliative care
Passively exposed to palliative care
Hospital palliative care team wishes to provide direct guidance to these facilities
Afraid that the facility’s caregivers lack the necessary skills and numbers	Indecisive about whether to introduce palliative care
Concerned about handling nighttime emergencies with limited staff
Unsure how to explain palliative care to families in detail
Troublesome for residents to pass away in the facility
Restrict the services initially to only those residents who met the qualifications for palliative care within the facility	Hospital palliative care team’s commitment to providing support
Promised to teach our caregivers how to care for the residents while they take care of them
Willing to provide 24-hour consultation service
Caregivers in the facility only need to provide a simple introduction to palliative care to residents and their families
Willing to issue death certificates and explain the cause of death to families
Provide integrated medical services
Provided a brief introduction to palliative care	Caregivers’ tasks	Playing a supportive role
If a resident had an emergency and the palliative care team could not arrive at the facilities promptly, the team would instruct the caregivers on how to handle the situation through communication software
The palliative care team also taught the caregivers some caregiving skills while providing palliative care to residents
Provide some simple and routine care
Caregivers being afraid of facing death	Caregivers encountered many difficulties
New caregivers’ ineffective learning of care techniques
Managers calming the emotions of the caregivers and telling them that they are doing a good thing	Caregivers gradually adapted and overcame the challenges
Caregivers are encouraged to express their feelings and concerns
Managers invite psychologists to provide spiritual counseling for caregivers
Managers cultivate experienced caregivers as seed teachers and gradually let the seed teachers instruct the new caregivers
Managers increase internal and external educational training in the facility
Caregivers’ care skills being enhanced	Positive changes in the facilities’ implementation of palliative care
Quality of care in the facilities has improved
Residents have actually extended their lifespan
The number of disputes regarding care has significantly decreased
Caregivers were unable to independently determine whether a patient was eligible for palliative care, handle sudden situations, or provide detailed explanations of palliative care	Recognizing the limitations of the assistance-only approach	New collaboration model
Caregivers lacking timeliness in responding to the residents’ situations
The services provided by the hospital palliative care team were also not comprehensive enough and mostly focused on the residents’ physical care
Two facilities establish their own palliative care teams	Developing a new collaboration model
Hospital palliative care team provides systematic education and training for caregivers
Caregivers providing comfort to residents and their families during end-of-life care
After the resident’s passing, the caregiver personally calls or visits the family to offer condolences and invites them to participate in the facilities’ bereavement care activities
An excessive number of critically ill patients transferred from hospital palliative care units	New challenges emerged and overcame
The hospital team agreed to increase their visits to the facility
Identify with the care philosophy and wholeheartedly dedicate themselves to their work, continually improve their skills	Established a new organizational culture
Generating caregivers’ self-worth and confidence
Encourage caregivers to continually improve
Able to fully grasp the knowledge and explanatory ability of palliative care	Professional abilities of caregivers have greatly improved	Facility transformation
Quality of care skills of caregivers has improved greatly
Become more confident
Become more mission-oriented
Whenever someone asks them which facility is better, they will enthusiastically recommend	Families of the deceased are very appreciative of the facilities’ efforts
Some families will volunteer as palliative volunteers at the facility
Facility often at full capacity so the revenue generated is relatively stable	Steadily operate the institution
Caregiver workforce has become more stable
Improve the quality of workforce
Establishing the first hospice in Taiwan, similar to those in the UK	High aspirations for the future
Become a training institution for palliative care nurses and caregivers

Table 2 Table with Categories and Core Category

Selective Coding
Category	Core Category
The opportunity for change	The palliative care captain in the facility
Playing a supportive role
New collaboration model
Facility transformation

Figure 1 The model of implemented palliative care by the nursing managers in long term care facility.

Table 3 Guidelines for the Implementation of Palliative Care at Various Stages by Long-Term Care Facility Managers

Stages	Potential Barriers	Possible Solutions
1. Initial Implementation (The opportunity for change)	1. Internal resistance due to pre-existing negative impressions, hindering the adoption 2. Hesitation to implement due to concerns about increased costs, burdens, and capacity	1. Gain a comprehensive understanding of the specific content, benefits, and implementation methods of palliative care to alleviate concerns 2. Outline deficiencies within the facility and seek support from palliative care teams
2. Collaboration Phase (Playing a supportive role)	Insufficient capacity among institutional staff remains an issue The introduction of the new model has sparked resistance due to the heightened physical and mental stress experienced by institutional employees.	Take on a supportive role within the palliative care team, observing and learning while being guided by more experienced and capable colleagues. Increase educational programs to enhance the skills of those lacking proficiency Proactively address the staff’s adaptation status, establish stress-relief mechanisms (such as work-sharing sessions or psychological counseling sessions).
Success Indicators at this Stage: ①Staff demonstrating technical proficiency and increased confidence ②Reduction in resident outpatient or emergency visits ③Extension of resident life expectancy ④Reducing the Occurrence of Disputes ⑤Increase in positive feedback from family members
3. Establishing Own Team (A new collaboration model)	There is still a time gap in the support provided by the palliative care team Staff fatigue within the facility is leading to a lack of motivation and a sense of achievement	Establish an in-house palliative care team within the organization, comprising doctors, nursing staff, social workers, psychologists, and religious leaders Transform the facility into a palliative care training center, with staff serving as instructors to encourage self-improvement and foster a sense of accomplishment
4. Seeking novelty and change (Facility transformation)	Excessive stability leading to organizational culture becoming stagnant and uninteresting. Success leading to complacency and stagnation.	Creating a Distinctive Feature: Recruiting family members of deceased residents as volunteers (providing mutual companionship /solace to one another’s spirits) Encouraging continuous training and further education for staff, setting more ambitious goals (such as becoming an exclusive end-of-life care institution/hospital)
Success Indicators at this Stage: ①Full bed occupancy ②Stable income ③Stable workforce (low turnover rate) ④Increased educational attainment among staff (obtaining higher degrees)