The purpose of the study was to gain a deeper understanding of how RNs in palliative care experienced and described confidential conversations. The main findings elucidate the importance of creating an interpersonal care relationship, regardless of time and occasion. The RNs described how the conversations were an important part of their work, were spontaneous and unpredictable, and often took place during the performance of other caring activities. This is in line with Moran et al (18) who describe how during various nursing activities, for example assistance with personal hygiene or wound dressings, RNs also perform several nursing actions that are rarely highlighted. RNs talk, observe, affirm, identify needs, and laugh together with the patients in order to create close relationships. In these naturally occurring conversations, existential questions arise to varying degrees. According to Macdonald (40), an everyday conversation, or small talk, can be a source of increased understanding and knowledge about the patient’s fears and may improve the patient´s quality of life. In palliative care, RNs can provide important opportunities for patients to talk about existential and spiritual issues (41).
In this study, the RNs found confidential conversations demanding due to their unpredictable content. However, the conversations could also be a source of new energy for the RNs, while at the same time safeguarding the PPCN. The confidential conversation offers enormous potential to meet the needs of PPCNs from a holistic perspective and is an important piece of the puzzle in palliative care to ensure that the patient has a dignified death. Meier et al (42) identified important features that impact the experiences of a good death, involving for example emotional wellbeing, spirituality, dignity, and relationships (42).
The confidential conversation was described in the present study as being trustful and that trust was created in both the interaction and the relationship. Moran et al (18) describe similar results and argue that, in a trustful relationship, the PPCN can talk confidently about difficult topics. According to Sekse et al (19), RNs provide the PPCN with existential and spiritual support through conversations. PPCNs receive help in managing their life situation, including illness, losses, dependence on help and support, as well as increased quality of life and a sense of independence and dignity (19). Both Hökkä et al (9) and White et al (10) argue that the conversation can be crucial for the interaction between RNs and PPCNs and the care relationship.
In the present study it was highlighted that the relationship between the RN and the PPCN was the most important aspect of a confidential conversation. Trust was built and this did not necessarily take a lot of time. The relationship constitutes both a prerequisite and an obstacle, and the RNs valued the relationship with the PPCN highly. This was described in the subtheme Being brave but careful; the RNs did not want to jeopardize the relationship by pushing the conversation too far. The relationship with the patient and their relatives is the very hub of nursing, as described in Davies and Oberles’ theory of supportive palliative care (20, 21). Their model presents different dimensions that have a great impact on the supportive care which can be secured by creating and maintaining relationships (contact) with the patient and relatives. According to Gillman et al (43), the relationship is also central to an RN’s ability to meet the patient’s emotional needs. RNs are aware that the effort they put into creating relationships also becomes a source of strength for themselves. Tarbi et al (16) state that the care relationship is a source of connection and togetherness. Strang et al (17) found that the conversation should not be forced, but should follow the PPCN’s energy, will and needs. This means that the RNs need to balance the conversation and the relationship, something that the RNs in our study also experienced. The RNs in our study achieved this balance through intuition, also described as the art of nursing. Henry (44) and Jenner (45) argue that the art of nursing is difficult to describe and understand. Recognising it as an art highlights the importance of the human aspects of nursing and includes the whole of nursing, says Wainwright (46). It is the essence of nursing, a way of being and knowing (44), a subjective process that demands intuition, sensitivity, and imagination (45). An artful moment is a moment of understanding between the patient and the nurse, which is the result of a genuine, productive relationship (44).
In the present study the PPCNs had limited time left in life, which created specific needs to talk and affected the conversation’s content. The RNs experienced that confidential conversations often included existential issues, and the RNs described how such content could affect them emotionally. Both Gillman et el (43) and Powell et al (47) argue that this is inevitable because the RNs are exposed to situations and events that arouse strong emotions. Strang et al (17) described how RNs have to deal with various emotional expressions together with the patient, which are sometimes difficult to manage and can make them feel drained. Gillman et al (43) argue that an individual’s ability to deal with strong emotions that arise in difficult situations is dynamic and influenced by personal, environmental, and contextual factors. Davies and Oberle (20, 21) refer to the concept of attitudes, arguing that attitudes are pervasive and concerned with approach and experience. Attitudes affect the entire relationship and are described as one of the dimensions of the theory of supportive palliative care (20, 21).
The RNs also described being the listener and not the solver. "Just being there" was described as challenging and made RNs unsure about how to respond. Childres et al (48) argue that in silence, space is created for feelings and thoughts. Knowing and intuitively feeling when silence is preferable, or when the conversation should instead be pushed further, is important and sometimes crucial for how the patient experiences the conversation. Brian et al (49) describe staying silent as an art, and that silence can help the PPCNs talk more about their feelings. To manage these complex responsibilities, RNs need courage, knowledge, experience, and personal skills. According to Tornöe et al (50) courage is needed to dare to raise existential questions despite feeling fear and uncertainty. The need for education, support from the team, supervision, and time is confirmed by both Gillman et al (43) and Keall et al (51). Tornöe et al (50) argue that learning to be quiet, to listen and be present in the moment increases the RN’s courage to dare to stay in the conversation. Parekh et al's study (52) showed that RNs who are allowed to practice conversations develop increased security and knowledge. Practice and education in conversations are important and give good results. Devery et al (53) claim that healthcare professionals need education and training to increase their skills and to feel secure in such conversations. They state that it is challenging to reach a point of shared consensus and mutual expectations where everyone involved needs to be heard.
The conversation could be a way to safeguard the PPCN. This involves helping the patient to find meaning by managing their illness or situation (finding meaning), performing nursing actions that the patient or relatives want help with (empowering), and using the appropriate resources for the physical care (doing for). The value and integrity of the patient can then be preserved and safeguarded (20, 21). Safeguarding one’s value and wholeness (preserving own integrity) is also central in Davies and Oberle’s (20, 21) model and is the foundation of nursing. We found that through the RNs preserving their own integrity and protecting their own limits, an opportunity can be created to be fully present in the meeting with the patient, which is also confirmed by Moran et al (18).
The RNs described that by confirming, preserving, and protecting in the conversation, the PPCN could feel strengthened and able to share their emotional burden. According to Tarbi et al (16), conversations about the changed body which has deteriorated, and how this affects the ill person can be perceived as both protective and confirmative. By talking about health, the normal, can also be a kind of safeguarding. Wang et al (54) describe how a lack of conversation with RNs can lead to the patient feeling neglected and unsure about their value and sense of belonging. The patient´s various feelings should instead be confirmed as being normal (17, 40) in order to preserve their values, desires and life situation (18). The RNs were also able to confirm and preserve the PPCNs´ integrity by allowing them to talk about the future, even though the time remaining was limited. This was perceived as empowering and could lead to maintaining dignity and wholeness, also confirmed by Elina et al (55). Siegle et al (56) believe that patients living with life-threatening diseases have different ways of coping and managing information, something that can change over time and during the course of the disease. It is, therefore, important that healthcare professionals are flexible and can adjust the conversations and the information given as appropriate (56). Michael et al (57) also emphasize a patient’s ability to adapt and cope with illness and impaired function. Adaptation and coping can be facilitated if the patient is treated with care, goodwill and trust. In conversations with patients, existential questions need a place where the patient’s values and life goals can be used as a starting point for optimizing care (57).
According to Sekse et al (19) the RN’s unique role and competence in palliative care is not always visible, and it is therefore crucial to recognize and highlight the importance of RNs. Nursing in palliative care also needs to adapt to new, technical tasks, while at the same time retain the very essence of palliative care, which is described as compassion, empathy, and genuine kindness. RNs strive to preserve the core of palliative care (19); however, this is challenging in a reality where there are increased technical demands (16), limited time, and high workloads (51). The RNs in our study described the same dilemma as the RNs in the study by Kealls et al (51), which is that, although high workloads result in reduced time spent with the patient, they anyway prioritize and create time for conversations.
The RNs may find clues in the confidential conversation that facilitate further conversations about prognosis and progress, and therefore become an important piece of the puzzle in palliative care. Kwak et al (58) point out the importance of conversations about the future and the prognosis requiring active listening and that RNs have an interest in spiritual needs and issues. The conversation should ensure a holistic view which is an important part of person-centred care (58). The RNs in our study describe the relationship as being central to the confidential conversation, which is conducted on the patient’s terms and based on the patient´s needs. The confidential conversation can provide information that can be considered in the upcoming care and thus become an obvious part of person-centred care, as described by McCormack (59) and Dewing et al (60).
Methodological considerations
Conversations with PPCNs about life and death are sometimes perceived as abstract and complex. A secondary analysis (31) was applied to an existing data set with the intention of gaining a deeper understanding through new research questions focusing on an aspect that was only partially addressed in the primary study. Using an interpretative approach to the analysis gave an additional understanding of the participants’ experiences. The data that was used had substantial and rich content, and efforts were made to use the primary data to the maximum and find the latent content.
A secondary analysis entails some methodological considerations (31). It is important to keep the ethics of informed consent in mind if data is to be reused in a secondary analysis. (61).
The study was based on interviews with nurses working in palliative care in order to ensure quality and trustworthiness, as described by Graneheim et al (62). The analysis and results were discussed in the research group in order to confirm dependability and reliability, and pre-understanding was particularly important to consider. During the study, members of the research group continualy discussed their pre-understanding, striving towards maintaining an approach that was as open-minded as possible. All members of the research group are RNs with experience from palliative and psychiatric care, where conversations are common and a natural part of nursing care. Pre-understanding can be an obstacle but also an asset, and the discussions about the impact of pre-understanding were pervasive. To ensure credibility and authenticity in the analysis (62), categories and themes were created with different levels of abstraction, and to show credibility the analysis was strengthened with quotes.
To ensure rigour in the analysis, the first author encoded the preliminary categories which were then discussed with the research group. As part of the reflexivity process, the themes were confirmed by supplementing and discussing the group’s comments, as well as their comprehension of the themes.
Strengths And Limitations
A strength of this study was the rich descriptions in the dataset of conversations that made it possible to deepen the analysis. It is of value to discuss how the data fits the new research questions according to Heaton (31). The research team read the interviews and deemed that the existing data was sufficient and could answer the new research questions, which is seen as a strength. However, it may be a limitation that the data collection took place on the basis of the research question and the purpose of the primary study. Even though specific in-depth questions about the confidential conversation were not used, the chosen method of analysis provided an opportunity for new, interpretive analyses, which led to a deeper understanding of the confidential conversation. An advantage of secondary analysis was the possibility to deepen the analysis of the phenomenon that the primary analysis only briefly described.
Heaton (31) discusses the limitations of secondary analysis from an ethical perspective and with a specific focus on consent, among other things. In the present study, informed consent was collected during data collection in the primary study. For the secondary analysis, no further consent could be obtained, which could be seen as a limitation. However, decisions were made on the grounds that the research questions in the secondary analysis were close to the original research questions.