Characteristics of included studies

The search and screening outcomes are presented in the PRISMA flow diagram shown in Figure 1. The literature was primarily qualitative and from the UK (Table 3). These articles explored various aspects of PC in acute hospital settings, with a focus on improving patient outcomes and experiences.

Figure 1. PRISMA flow diagram.

Table 3. A matrix of country versus type of study

Table 4 presents the characteristics of the 25 articles. The key commonalities and differences were identified from the data extracted. Several studies highlighted the need for early identification and involvement of PC specialists to improve patient outcomes, symptom management, and discharge planning (Coombs et al. Reference Coombs, Nelson and Psirides2016; Bone et al. Reference Bone, Evans and Henson2019, Reference Bone, Evans and Henson2021; Chen et al. Reference Chen, Walabyeki and Johnson2019; Killackey et al. Reference Killackey, Lovrics and Saunders2020; Quinn et al. Reference Quinn, Stukel and Stall2020; Sweeny et al. Reference Sweeny, Alsaba and Grealish2024). Effective communication and coordination among health care professionals, patients, and families were also identified as being crucial for providing quality PC (Fox et al. Reference Fox, Windsor and Connell2016; Nevin et al. Reference Nevin, Hynes and Smith2020; Redwood et al. Reference Redwood, Simmonds and Fox2020; Morey et al. Reference Morey, Scott and Saunders2021; Shepherd et al. Reference Shepherd, Waller and Sanson-Fisher2021). Several studies emphasized the importance of addressing the physical, psychological, social, spiritual, and cultural needs of patients and their families at the EOL (Coombs et al. Reference Coombs, Fulbrook and Donovan2015; Virdun et al. Reference Virdun, Luckett and Lorenz2016; Donnelly et al. Reference Donnelly, Prizeman and Dó2018; O’Brien et al. Reference O’Brien, Kinloch and Groves2019; Robinson et al. Reference Robinson, Moeke-Maxell and Parr2020; Reid et al. Reference Reid, Dennis and Hoad2023). Other articles identify various barriers to providing optimal PC in acute care settings, including organizational and systemic issues, lack of resources, and communication difficulties (Southern District Health Board 2018; Nevin et al. Reference Nevin, Hynes and Smith2020; Shepherd et al. Reference Shepherd, Waller and Sanson-Fisher2021; Xiong et al. Reference Xiong, Stirling and Martin-Khan2023; Omoya et al. Reference Omoya, De Bellis and Breaden2024).

Table 4. Eligible articles’ characteristics

The studies focus on different patient populations, including those with specific diseases (Fox et al. Reference Fox, Windsor and Connell2016; Bailey et al. Reference Bailey, Hewison and Karasouli2016; Quinn et al. Reference Quinn, Stukel and Stall2020; Piazza and Drury Reference Piazza and Drury2023), older adults (Bone et al. Reference Bone, Evans and Henson2019, Reference Bone, Evans and Henson2021; Sweeny et al. Reference Sweeny, Alsaba and Grealish2024), and patients in various stages of illness (Bajwah et al. Reference Bajwah, Oluyase and Yi2020; Morey et al. Reference Morey, Scott and Saunders2021). The articles investigate a range of interventions, such as care coordination, specialist PC teams, and supportive care, and examine their impact on various outcomes, including symptom management, quality of life, and patient and family satisfaction (Coombs et al. Reference Coombs, Fulbrook and Donovan2015; Bone et al. Reference Bone, Evans and Henson2019; Bajwah et al. Reference Bajwah, Oluyase and Yi2020; Quinn et al. Reference Quinn, Stukel and Stall2020; Piazza and Drury Reference Piazza and Drury2023). The articles employ diverse research methodologies (Table 3), including qualitative, quantitative, and mixed-methods approaches, to explore different aspects of PC in acute care (e.g., patient experiences, health care professional perspectives, and service models).

Synthesis of results

While there was extensive literature on PC nursing, relatively little was focused on the acute care hospital setting. This finding, in itself, reveals the need for research targeted in this area so that a more in-depth understanding of the roles and responsibilities of PC nursing in acute care is gained. The following sections will examine nine key areas identified in the review (Figure 2), reflecting the multifaceted nature of PC nursing in the acute care setting and highlighting the need for further research and policy development to support meeting the needs of hospital patients with life-limiting illnesses and the nurses who care for them.

Figure 2. Key areas of palliative care nursing practice identified by the scoping review.

Coordination of care, communication, and facilitation

Within the hospital setting, the fragmentation of services was often found to lead to poor communication, discharge planning, and care coordination, requiring specialized PC nursing services to bring it all together (Fox et al. Reference Fox, Windsor and Connell2016; Bailey et al. Reference Bailey, Hewison and Karasouli2016; Virdun et al. Reference Virdun, Luckett and Lorenz2016; Chen et al. Reference Chen, Walabyeki and Johnson2019; Bajwah et al. Reference Bajwah, Oluyase and Yi2020; Nevin et al. Reference Nevin, Hynes and Smith2020; Redwood et al. Reference Redwood, Simmonds and Fox2020; Shepherd et al. Reference Shepherd, Waller and Sanson-Fisher2021; Reid et al. Reference Reid, Dennis and Hoad2023; Sweeny et al. Reference Sweeny, Alsaba and Grealish2024). The literature highlighted that PC nurses play a crucial role in bridging gaps, coordinating care, facilitating communication in complex situations, ensuring effective transfer of information across settings, and actively participating in patient management planning.

The handing over of patients between different services, for example, from ED to a ward, can be fraught with confusion around the ceiling of care agreed on by patients and families, after assessment by a medical team. High workload volumes in acute areas meant that conversations were not being had by a patient’s treating team, leaving PC services to address with family, why certain interventions were not being administered, and others withdrawn (Fox et al. Reference Fox, Windsor and Connell2016; Redwood et al. Reference Redwood, Simmonds and Fox2020; Shepherd et al. Reference Shepherd, Waller and Sanson-Fisher2021). Three articles noted that the translation of medical information and decisions to patients and families was often left for PC nursing teams to pick up after the initial assessment (Bailey et al. Reference Bailey, Hewison and Karasouli2016; Virdun et al. Reference Virdun, Luckett and Lorenz2016; Killackey et al. Reference Killackey, Lovrics and Saunders2020; Nevin et al. Reference Nevin, Hynes and Smith2020). Effective and compassionate communication was critical to gain a shared understanding of the situation and often relied on the extra time available for PC teams once the patient has been transferred out of an acute assessment area (Bailey et al. Reference Bailey, Hewison and Karasouli2016; Virdun et al. Reference Virdun, Luckett and Lorenz2016; Nevin et al. Reference Nevin, Hynes and Smith2020).

PC nursing teams were found to provide support, not only to patients and their caregivers but also to doctors making decisions to withdraw treatment or discontinue futile interventions being mentioned in several articles (Virdun et al. Reference Virdun, Luckett and Lorenz2016; Bajwah et al. Reference Bajwah, Oluyase and Yi2020; Nevin et al. Reference Nevin, Hynes and Smith2020; Shepherd et al. Reference Shepherd, Waller and Sanson-Fisher2021). Lack of experience and expertise in junior doctors, low confidence, uncertain prognosis, and fear of saying the wrong thing were barriers to communicating well with EOL patients (Virdun et al. Reference Virdun, Luckett and Lorenz2016; Bajwah et al. Reference Bajwah, Oluyase and Yi2020; Nevin et al. Reference Nevin, Hynes and Smith2020; Shepherd et al. Reference Shepherd, Waller and Sanson-Fisher2021). Clinicians could sometimes feel awkward in bringing up the topic of death and dying, and family members may have been too scared to ask questions, leaving the people involved feeling confused and worried about what is happening with the PC nurse being viewed as the “safety net” for these families (Chen et al. Reference Chen, Walabyeki and Johnson2019; Redwood et al. Reference Redwood, Simmonds and Fox2020; Bone et al. Reference Bone, Evans and Henson2021; Omoya et al. Reference Omoya, De Bellis and Breaden2024). On the other hand, if difficult conversations had taken place, the PC nurse’s expertise in communication skills was often vital to facilitate a shared understanding of the situation and for de-escalation (Fox et al. Reference Fox, Windsor and Connell2016; Chen et al. Reference Chen, Walabyeki and Johnson2019; Bajwah et al. Reference Bajwah, Oluyase and Yi2020). The phrase “PC” can be confronting for a patient as they realize treatment may have come to an end, and they are looking to the next stage which involves trying to gain some quality of life for what time remains. Three studies found that by the time patients with a life-limiting illness talk to the PC team, emotions were heightened and complex communication skills were required along with de-escalation of difficult conversations that may have taken place between a consultant and the patient (Fox et al. Reference Fox, Windsor and Connell2016; Chen et al. Reference Chen, Walabyeki and Johnson2019; Bajwah et al. Reference Bajwah, Oluyase and Yi2020). The research identified that effective and compassionate communication was critical to gaining a shared understanding of the situation, and often relied on the extra time available for PC teams once the patient has been transferred out of an acute assessment area.

As well as liaising between doctors and patients, recognizing and coordinating patient care across different inpatient settings was also identified as part of PC nursing services. The research emphasized that PC nurses act as a liaison between various MDTs, such as occupational therapy, physiotherapy, and social work (Bailey et al. Reference Bailey, Hewison and Karasouli2016; Bajwah et al. Reference Bajwah, Oluyase and Yi2020; Reid et al. Reference Reid, Dennis and Hoad2023; Sweeny et al. Reference Sweeny, Alsaba and Grealish2024). Facilitating MDT reviews, arranging symptom support services such as domiciliary oxygen, updating primary care or community teams and arranging follow-up services if a patient was discharged home were just some of the areas that needed to be addressed thoughtfully for successful patient outcomes (Bailey et al., Reference Bailey, Hewison and Karasouli2016; Bajwah et al. Reference Bajwah, Oluyase and Yi2020; Reid et al. Reference Reid, Dennis and Hoad2023; Sweeny et al. Reference Sweeny, Alsaba and Grealish2024). The studies reviewed highlight the importance of these collaborative efforts in enhancing the overall quality of PC.

Together the literature has revealed that PC nurses play a key role in coordinating care and facilitating communication within the acute hospital setting. PC nurses bridge gaps in service delivery and ensure effective information transfer. The PC nurse’s expertise in communication is particularly crucial in navigating difficult conversations and ensuring a shared understanding among all involved parties to enhance the overall quality of PC and improve patient and family experiences.

Decision-making, goals, and expectations

PC nurses were found to contribute to decision-making processes, helping patients and families define goals of care, set and manage expectations, and identify gaps in care. Decision-making around cares was a focus of two studies (Fox et al. Reference Fox, Windsor and Connell2016; Reid et al. Reference Reid, Dennis and Hoad2023). As part of the patient assessment, PC nurses are well placed to facilitate decisions around optimizing quality of life and the current functional status. In the acute care environment, which can look very different compared to what home might be like, shared decision-making was identified as a strong part of patient-centered care (Fox et al. Reference Fox, Windsor and Connell2016; Reid et al. Reference Reid, Dennis and Hoad2023). The identification of gaps in care, particularly for patients with non-oncological conditions, and the facilitation of the advance care plan (ACP) discussions were identified as important responsibilities of PC nurses.

Two research papers found the ACP discussion was a task often picked up by PC nurses during inpatient stays (Redwood et al. Reference Redwood, Simmonds and Fox2020; Sweeny et al. Reference Sweeny, Alsaba and Grealish2024). The ACP documents the treatments and cares that a patient might want towards the EOL, and those interventions they would prefer to avoid, and is a key part of goal-setting. Creating or updating ACPs not only helped to identify patients nearing the EOL and prepared their caregivers for what was coming up, but more importantly, the presence of the ACP was useful in avoiding inappropriate referrals and admissions which could result in further functional decline (Redwood et al. Reference Redwood, Simmonds and Fox2020; Sweeny et al. Reference Sweeny, Alsaba and Grealish2024). These research articles found that many times, it was the PC team that alerted the treating clinician that an ACP was in place to guide the patient’s preferences of care.

Goals of care was an area that required more focus and consideration, not only in the broad sense of what is appropriate but also what the patient has defined as acceptable. PC nurses spend considerable time at the bedside, discussing imminent and future goals with patients and families – an area with many expectations from the patient and family. This facet of assessment was mentioned in most of the articles, however, more specifically discussed in six of them (Fox et al. Reference Fox, Windsor and Connell2016; Chen et al. Reference Chen, Walabyeki and Johnson2019; Killackey et al. Reference Killackey, Lovrics and Saunders2020; Nevin et al. Reference Nevin, Hynes and Smith2020; Reid et al. Reference Reid, Dennis and Hoad2023; Shepherd et al. Reference Shepherd, Waller and Sanson-Fisher2021; Xiong et al. Reference Xiong, Stirling and Martin-Khan2023). Helping to identify and achieve goals such as getting out of the hospital, staying away from ED, identifying clinical risks and preferences for care, working out how to align clinicians, patient’s and families’ ideas of EOL, finding opportunities for personal growth with limited time, goals for dying well and choosing where to die, were all areas where there was an expectation of PC nurse involvement (Fox et al. Reference Fox, Windsor and Connell2016; Chen et al. Reference Chen, Walabyeki and Johnson2019; Nevin et al. Reference Nevin, Hynes and Smith2020; Reid et al. 2021; Shepherd et al. Reference Shepherd, Waller and Sanson-Fisher2021; Xiong et al. Reference Xiong, Stirling and Martin-Khan2023). Not only were these goals discussed around the acute inpatient setting, but PC teams were required to broaden this discussion to how life will look in the community, as part of planning for discharge.

Identifying gaps in care was discussed in five studies (Bailey et al. Reference Bailey, Hewison and Karasouli2016; Bone et al. Reference Bone, Evans and Henson2019, Reference Bone, Evans and Henson2021; Quinn et al. Reference Quinn, Stukel and Stall2020; Redwood et al. Reference Redwood, Simmonds and Fox2020). Non-oncological disease trajectories can be drawn out over several years, in the case of heart failure, chronic obstructive pulmonary disease (COPD) or renal failure. Not only are PC nurses expected to identify the gaps found in the acute system, the studies indicated that education of the patient by PC nursing teams was crucial for living well and staying out of hospital, especially in the context of unlikelihood of hospice community programme admission (Bailey et al. Reference Bailey, Hewison and Karasouli2016; Bone et al. Reference Bone, Evans and Henson2019, Reference Bone, Evans and Henson2021; Quinn et al. Reference Quinn, Stukel and Stall2020; Redwood et al. Reference Redwood, Simmonds and Fox2020).

The research also highlights that PC nurses play a role in prognosticating illness, a task that can be challenging due to factors such as clinician inexperience and the unpredictable trajectory of non-oncological diseases (Bailey et al. Reference Bailey, Hewison and Karasouli2016; Virdun et al. Reference Virdun, Luckett and Lorenz2016; Bajwah et al. Reference Bajwah, Oluyase and Yi2020; Nevin et al. Reference Nevin, Hynes and Smith2020; Shepherd et al. Reference Shepherd, Waller and Sanson-Fisher2021). Prognostication, while initially the role for the consultant/lead clinician, has become an unwelcome role for PC nurses, especially toward the imminent EOL as family members want frequent updates on how long their loved-one has left to live. Findings suggested that some of the reasons that prognosis was challenging were clinician inexperience, inability to relate to grieving families, not wanting to deliver sad news, and difficulty in understanding the trajectory of non-oncological diseases (Bailey et al. Reference Bailey, Hewison and Karasouli2016; Virdun et al. Reference Virdun, Luckett and Lorenz2016; Bajwah et al. Reference Bajwah, Oluyase and Yi2020; Nevin et al. Reference Nevin, Hynes and Smith2020; Shepherd et al. Reference Shepherd, Waller and Sanson-Fisher2021).

Collectively, the literature details the pivotal role of PC nurses in facilitating patient- and family-centered care within the acute setting. The research acknowledges the involvement of PC nurses in shared decision-making, assisting patients and families in defining goals of care, setting realistic expectations, and identifying gaps in care. The complexities of prognostication, particularly in non-oncological diseases, and the importance of advance care planning discussions are also emphasized. The literature illustrates that PC nurses play a crucial role in bridging the gap between patient/family expectations and the realities of the acute care environment, advocating for patient autonomy and informed decision-making.

Discharge planning

Almost half the literature reviewed mentioned discharge planning as a common and expected task of PC nursing teams (Table 4, Figure 2). The research showed the significance of discharge planning in ensuring a smooth transition for patients and their families from the hospital to their preferred care setting, whether it be home, hospice, or another facility, with a seamless and coordinated approach to discharge improving the success of PC. PC nursing teams supported continuity of care in the acute setting by acting as a bridge from hospital to home, having already been involved in goals of care discussions, early referral to primary PC services in the community, and assessment in hospital (inpatient wards and ED) for symptom management (Morey et al. Reference Morey, Scott and Saunders2021; Sweeny et al. Reference Sweeny, Alsaba and Grealish2024). In turn, effective discharge planning contributed to reduced readmission rates and enabled patients to receive appropriate care in their chosen setting (Fox et al. Reference Fox, Windsor and Connell2016; Bone et al. Reference Bone, Evans and Henson2019; Killackey et al. Reference Killackey, Lovrics and Saunders2020; Morey et al. Reference Morey, Scott and Saunders2021; Quinn et al. Reference Quinn, Stukel and Stall2020; Redwood et al. Reference Redwood, Simmonds and Fox2020; Sweeny et al. Reference Sweeny, Alsaba and Grealish2024).

Information sharing was a key role PC nurses undertook to expedite complex discharges, provide information about community resources, and facilitate access to necessary equipment and medications. PC nursing teams worked with allied health MDTs to support and facilitate rapid and complex discharges back to the patient’s home, either with district nursing or community hospice support (Paes et al. Reference Paes, Ellershaw and Khodabukus2018). Information sharing by PC teams between systems meant that discharge delays were less likely, and readmission rates were reduced (Bone et al. Reference Bone, Evans and Henson2019; Redwood et al. Reference Redwood, Simmonds and Fox2020). As part of their role, PC nursing teams liaised with community services to help patients stay in their homes or facilities. Bone et al. (Reference Bone, Evans and Henson2021) found that in the last year of life, many older and frail adults were admitted to the ED for crisis admission, yet they would prefer to remain in their usual environments and have PC support in the community. The research by Coombs et al. (Reference Coombs, Nelson and Psirides2016) revealed the need for a better understanding of what an acute rapid response team can offer a dying patient and when they should be transferred to the care of the PC team. If in the acute care setting, a referral to PC services occurs, the coordination and early assessment by PC teams meant those with a life-limiting illness were more likely to die at home as preferred, due to the discharge supports in place (Fox et al. Reference Fox, Windsor and Connell2016; Quinn et al. Reference Quinn, Stukel and Stall2020).

Thus, the PC nurses play important roles in facilitating effective discharge planning, which contributes to reduced readmissions, improved patient and family experiences, and help to fulfil patient preferences for EOL care. Early referrals, information sharing, and collaboration with MDTs ensure continuity of care and support of patients’ choices regarding their preferred place of care and death.

Physical symptom management

As expected, over half of the articles highlighted symptom management as the most important facet of PC nursing team assessment (O’Connor et al. Reference O’Connor, Palfreyman and Le2016; Virdun et al. Reference Virdun, Luckett and Lorenz2016; Bone et al. Reference Bone, Evans and Henson2019; Chen et al. Reference Chen, Walabyeki and Johnson2019; Henson et al. Reference Henson, Maddocks and Evans2020; Morey et al. Reference Morey, Scott and Saunders2021; Quinn et al. Reference Quinn, Stukel and Stall2020; Redwood et al. Reference Redwood, Simmonds and Fox2020; Shepherd et al. Reference Shepherd, Waller and Sanson-Fisher2021; Reid et al. Reference Reid, Dennis and Hoad2023; Sweeny et al. Reference Sweeny, Alsaba and Grealish2024; Xiong et al. Reference Xiong, Stirling and Martin-Khan2023). In a review of the need for care coordination and shared goals of care, the combined Australian, Norway, and UK comparative study noted that both symptom management and minimization of harm were the most important components of EOL care (Xiong et al. Reference Xiong, Stirling and Martin-Khan2023). Other studies from the UK identified having a PC team nurse to assist during admissions with unstable symptoms as an environmental enabler of health when it came to older people living with frailty and turned the conversations away from diagnosis and life-preserving treatment and more toward quality of life remaining (Bone et al. Reference Bone, Evans and Henson2019; Redwood et al. Reference Redwood, Simmonds and Fox2020). In another UK study of a PC team that attended ED to manage ED presentations in patients diagnosed with terminal cancer with symptoms of pain, nausea, and constipation, it was found that this relationship between the PC team and ED helped to reduce recurrent admissions, improve patient experiences and increased support at the primary level (Chen et al. Reference Chen, Walabyeki and Johnson2019). Canadian studies have also found that PC teams delivering symptom management assessment and advice in the hospital setting to both cancer and non-cancer related terminal illness patients enabled several positive health outcomes. Patients experienced reduced hospital admission with fewer symptom-related ED visits, which increased their odds of dying at home as a preference, and for those who remained as inpatients for EOL, the overall dying experience for patients and families was improved (Morey et al. Reference Morey, Scott and Saunders2021; Quinn et al. Reference Quinn, Stukel and Stall2020; Reid et al. Reference Reid, Dennis and Hoad2023). Similarly, in a meta-synthesis by Virdun et al. (Reference Virdun, Luckett and Lorenz2016) that reviewed 16 articles it was found that symptom management at EOL was one of the most important parts of PC in the hospital setting, according to patient and family. Timely and effective relief of physical symptoms, commencement of syringe drivers, and symptom education and support to families were other aspects discussed across the literature (Fox et al. Reference Fox, Windsor and Connell2016; Southern District Health Board 2018; Sweeny et al. Reference Sweeny, Alsaba and Grealish2024). One study identified the lack of a PC team in the acute setting to be one of the top 5 barriers in effective EOL care (Shepherd et al. Reference Shepherd, Waller and Sanson-Fisher2021). Therefore, PC nurses play a key role in assessing, treating, and managing physical symptoms, with effective symptom management improving patients’ quality of life and reducing the need for ED visits and further hospital admissions.

Holistic symptom management

Although only one article had the words “spiritual” in its title, many of the articles, as outlined below, discussed spiritual support, along with other ways to provide holistic care for patients with a very limited life expectancy in the hospital setting. The concept of holistic symptom management extends beyond physical symptoms to encompass the psychological, spiritual, social, and existential needs of patients and their families. PC nurses play a crucial role in addressing these multifaceted needs, recognizing the interconnectedness of these dimensions in the experience of suffering (Fox et al. Reference Fox, Windsor and Connell2016). However, the construction of PC definitions has created tension within some clinical cultures and ambiguity around what holistic care means for EOL patients, with many considering that symptom management should be predominantly concerned with physical issues (Fox et al. Reference Fox, Windsor and Connell2016). Nevertheless, provision of emotional and psychological support at EOL and facilitating connections appears to have become defined as part of PC teams’ holistic assessment as well as coordinating these and other support services in the acute setting and that included pre-bereavement and anticipatory grief work; the latter classed as specialist PC interventions (Donnelly et al. Reference Donnelly, Prizeman and Dó2018; Paes et al. Reference Paes, Ellershaw and Khodabukus2018; Bajwah et al. Reference Bajwah, Oluyase and Yi2020; Bone et al. Reference Bone, Evans and Henson2021; Reid et al. Reference Reid, Dennis and Hoad2023).

The literature highlighted that families had an understanding that PC nursing teams would meet all the care needs of their loved ones, particularly making everyone feel comfortable about death and dying, as well as caring for the patient physically, emotionally and/or spiritually, and expressed disappointment and disconnection when this was not the case (Fox et al. Reference Fox, Windsor and Connell2016; Virdun et al. Reference Virdun, Luckett and Lorenz2016; Morey et al. Reference Morey, Scott and Saunders2021). It was noted that attending to the patient’s psychological and existential requirements took time, which was a barrier in the acute setting, meaning that there was a need for this role to be taken up by PC teams (Nevin et al. Reference Nevin, Hynes and Smith2020). Unfortunately, one study revealed that 30% of nurses in PC found spiritual and religious facets of care problematic, in part, because they were untrained in these matters (Shepherd et al. Reference Shepherd, Waller and Sanson-Fisher2021). In addition, O’Brien et al. (Reference O’Brien, Kinloch and Groves2019) highlighted that it was not the main responsibility of the chaplaincy service to recognize spiritual distress but instead all PC staff should be trained to identify spiritual needs and should feel comfortable to provide at least a basic level of spiritual care and engaging the Chaplain services when appropriate. Patients were reportedly appreciative when nurses and health care professionals considered their existential needs (O’Brien et al. Reference O’Brien, Kinloch and Groves2019). Understanding that spiritual care and bereavement were so important to the overall well-being of the EOL patient, one UK Hospital PC team has dedicated staff to assist with this facet of symptom management (Paes et al. Reference Paes, Ellershaw and Khodabukus2018). In NZ, one regional hospital policy document requires the PC team to facilitate access to culturally appropriate services for inpatients in the acute setting and recommends that referrals be made for newly diagnosed oncology patients who may need psychological and social work assistance to the dedicated cancer psychosocial team (Southern District Health Board 2018).

The findings presented in this section highlight the challenges faced by PC nurses in providing comprehensive holistic care within the acute setting, particularly in addressing spiritual and existential needs due to time constraints, lack of training, and role ambiguity. The research has reiterated the importance of recognizing and addressing these multifaceted needs to ensure a truly patient- and family-centered approach to PC. The studies suggest that dedicated staff and training in spiritual care, as well as collaboration with other health care professionals like social workers and chaplains, can enhance the provision of holistic support and improve the overall well-being of patients and their families at the EOL.

Finances

The financial aspects of PC are also addressed in the literature, with a focus on both institutional and personal finances. PC nurses may be involved in navigating funding streams for resources to support patients at home or in higher-level care facilities (Bailey et al. Reference Bailey, Hewison and Karasouli2016; Quinn et al. Reference Quinn, Stukel and Stall2020). They may also assist patients and families in addressing financial concerns that can contribute to existential distress, either directly or indirectly through referrals to social workers or psychosocial support teams (Virdun et al. Reference Virdun, Luckett and Lorenz2016).

Environment

Creating a supportive and comfortable environment for patients nearing the EOL is another important aspect of PC nursing. The research highlights the challenges of finding appropriate spaces within acute hospital settings that allow for privacy, family involvement, and a sense of peace and dignity (Reid et al. Reference Reid, Dennis and Hoad2023). Locating the most appropriate environment for patients who cannot return home and who have less than six weeks to live, as well as those who are imminently dying has become part of the tasks taken on by a PC team. Two studies highlighted that adequate environments for extended family care and support were deficient in acute hospital wards, which did not have spaces that could be personalized to suit the needs of the patient and family (Reid et al. Reference Reid, Dennis and Hoad2023; Omoya et al. Reference Omoya, De Bellis and Breaden2024). PC nurses play a key role in advocating for patients’ needs and collaborating with other health care professionals to ensure that the physical environment contributes to their overall well-being (Virdun et al. Reference Virdun, Luckett and Lorenz2016; Donnelly et al. Reference Donnelly, Prizeman and Dó2018; Reid et al. Reference Reid, Dennis and Hoad2023).

A key feature in PC assessment is identifying that the patient is deteriorating and requires a side/single room, and the speed of this happening was often dependent on the bed status in the hospital at any one time, and liaising with duties managers and charge nurses while negotiating visiting relatives in tight and public spaces was all part of providing optimal PC (Virdun et al. Reference Virdun, Luckett and Lorenz2016; Reid et al. Reference Reid, Dennis and Hoad2023). The importance of finding a single room was noted to be the overall key factor in a two-site hospital bereavement study, which influenced the dying experience in the acute setting (Donnelly et al. Reference Donnelly, Prizeman and Dó2018). This concept of selecting an appropriate environment is discussed in Robinson et al. (Reference Robinson, Moeke-Maxell and Parr2020), as a way to honor our bicultural society in NZ, taking into consideration the needs of Māori during the anticipatory grief period and beyond, as a way to truly show compassion in our nursing care. Another NZ article describing EOL-care nursing practices in intensive care units echoed this idea that finding a culturally appropriate place for whanau to support their dying people was not only important but also aligned with the Treaty of Waitangi to underpin nursing practice (Coombs et al. Reference Coombs, Fulbrook and Donovan2015). However, unlike the previous article, the authors reported that NZ ICUs do this well, along with their framework for holistic care – which was not a finding in most of the other reviews on similar acute settings.

The research findings highlight the critical role of PC nurses in advocating for and creating a supportive environment for patients at the EOL. The challenges of securing appropriate spaces within acute care settings that prioritize privacy, family involvement, and a sense of peace and dignity are evident. Furthermore, the ability of PC nurses to navigate these challenges and collaborate with other health care professionals to optimize the patient’s environment significantly impacts the overall quality of EOL care and the dying experience for both patients and their families.

Education

The literature emphasized the importance of education to enhance understanding and improve the quality of care for patients with life-limiting illnesses. PC nurses are actively involved in educating patients, families, and other health care professionals about EOL care. Ongoing education to non-palliative-trained staff, as well as patients and families, is vital to ensure improved care of the dying and a better understanding of the process for patients and caregivers. PC nurses provide information about symptom management, advance care planning, and available resources (Donnelly et al. Reference Donnelly, Prizeman and Dó2018; Southern District Health Board 2018; Killackey et al. Reference Killackey, Lovrics and Saunders2020; Nevin et al. Reference Nevin, Hynes and Smith2020). The research indicated that patient education by PC nursing teams was highly beneficial for living well and staying out of the hospital, especially in the context of the unlikelihood of hospice admission (Bailey et al. Reference Bailey, Hewison and Karasouli2016; Bone et al. Reference Bone, Evans and Henson2019, Reference Bone, Evans and Henson2021; Quinn et al. Reference Quinn, Stukel and Stall2020; Redwood et al. Reference Redwood, Simmonds and Fox2020). PC teams were also responsible for teaching junior doctors and visiting nurses during patient rounds to support their practice, as well as delivering ACP education (Donnelly et al. Reference Donnelly, Prizeman and Dó2018; Southern District Health Board 2018; Nevin et al. Reference Nevin, Hynes and Smith2020). In NZ, the importance of education is reflected in the local district health board Service Plan for PC which includes a robust PC education program to support nursing and allied health staff across the two Southern sites and their hospices, through in-person teaching days as well as making resources available for staff and patients (Southern District Health Board 2018).

Rapid review

The need for rapid review and initiation of care by PC teams is often driven by delays in referrals. Unfortunately, many consultants are reluctant to acknowledge or unable to identify the decline to EOL leading to late referral to the PC team, which in turn leads to insufficient time to assess and follow up, difficulty in making decisions to withdraw care, and support patients in acceptance of a more supportive pathway (Fox et al. Reference Fox, Windsor and Connell2016; Paes et al. Reference Paes, Ellershaw and Khodabukus2018; Southern District Health Board 2018; Nevin et al. Reference Nevin, Hynes and Smith2020; Quinn et al. Reference Quinn, Stukel and Stall2020; Piazza and Drury Reference Piazza and Drury2023). Regardless of the increased workload, PC nurses play a crucial role in addressing these challenges associated with late referral, ensuring timely and compassionate care for patients nearing the EOL. The importance of early engagement with PC teams for oncology patients nearing the EOL, allowing sufficient time for review in order to introduce the various community supports available to prevent recurrent ED presentations was highlighted in several studies (Virdun et al. Reference Virdun, Luckett and Lorenz2016; Southern District Health Board 2018; Chen et al. Reference Chen, Walabyeki and Johnson2019; Morey et al. Reference Morey, Scott and Saunders2021; Piazza and Drury Reference Piazza and Drury2023). Results from Coombs et al. (Reference Coombs, Nelson and Psirides2016), concur with these articles, that early assessment, education, and referral to a ward-based PC team, can help reduce unwanted interventions and pointless escalation by acute medical response teams at EOL.

Bereavement support: An expectation

While bereavement support is recognized as an important aspect of PC, it is often challenging for PC nurses to provide this service due to time constraints and staffing. Nevertheless, this seems to be an expectation that caregivers have of acute PC nurses. In a country where 43% of people die in the acute hospital setting, a study from Ireland has found that bereavement support was lacking in these environments; with areas such as follow-up contact from a counsellor, provision of a memorial service, links to a support group, or financial entitlement needing improvement (Donnelly et al. Reference Donnelly, Prizeman and Dó2018). Virdun et al. (Reference Virdun, Luckett and Lorenz2016) found that adequate family preparation before death, time to say goodbye, and a system to follow up or assist with bereavement were an expectation of family and caregivers that were not realized. Pre-bereavement interventions and post-death support were important factors for caregivers of patients with advanced illness who had died in acute hospitals, in a cost-effectiveness study into hospital-based specialist PC, where it was also mentioned that hospital resources are scarce and need to be allocated judiciously (Bajwah et al. Reference Bajwah, Oluyase and Yi2020). The literature, therefore, highlights the discrepancy between the expectations of bereavement support from families and the capacity of acute care PC teams to provide it adequately. The scarcity of resources and the demanding nature of acute care settings often hinder the provision of comprehensive bereavement services, leaving a gap in care for grieving families. The findings highlight the need for increased resources and support for PC nurses to address bereavement needs and ensure a more holistic approach to EOL care that extends beyond the immediate needs of the patient. The importance of such care as part of engagement with patients and their families is reflected in the SDHB service plan, whereby acute needs are attempted to be met in the hospital in a broader holistic manner until other care teams are able to meet these needs (Southern District Health Board 2018). Table 5 summarizes the breadth of roles and responsibilities associated with PC nursing identified in the literature.

Table 5. Summary of roles and responsibilities associated with palliative care nursing

Limitations

Studies published prior to 2014 and studies not published in English were excluded. Researcher bias may have influenced the selection of studies and the extraction of data, as the process requires subjective decision-making regarding study inclusion and exclusion criteria. As with all reviews, there is the risk of publication bias, as some research is less likely to be published. The included studies presented data from countries other than New Zealand which may limit the transferability of the findings. In addition, there is limited research involving patient perspectives as PC patients are an extremely vulnerable population. As a result, all available research may not be included in this review; however, the objective is to understand the breadth of available research.