Development of the Short-Term Life Review Performed by Nurses as Spiritual and Psychological Care for Terminally Ill Cancer Patients
Published Date: October 05, 2017
Development of the Short-Term Life Review Performed by Nurses as Spiritual and Psychological Care for Terminally Ill Cancer Patients
Michiyo Ando1*, Tatsuya Morita2, Keio Tamura3, Kaori Fukuta4, Kengo Imai5, Atsuko Yoshida6, and Yosuke Uchitomi7
1Faculty of Nursing, St. Mary’s College, Kurume City, Fukuoka, Japan
2Palliative and Supportive care Division, Seirei Mikatahara General Hospital, 3453 Mikataharacho, Hamamatsu, Japan
3Palliative Nursing, Department of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
4Department of Nursing, Seirei Mikatahara General Hospital, 3453 Mikataharacho, Hamamatsu, Japan
5Seirei Hospice, Seirei Mikatahara General Hospital, 3453 Mikataharacho, Hamamatsu, Japan
6Kyoto Vihara Hospital, Japan
7Innovation Center for Supportive, Palliative and Psychosocial Care, & Dept. of Psycho-Oncology, National Cancer Center Hospital, & QOL Research Group, Center for Public Health Sciences, National Cancer Center, Japan
*Corresponding author: Michiyo Ando, St. Mary’s College, Tsubukuhonmachi 422, Kurume city, Fukuoka, Japan, Tel: 81-942-50-0744; Fax: 81-942-34-9125; E-mail: firstname.lastname@example.org
Citation: Ando M, Morita T, Tamura K, Fukuta K, Imai K, et al. (2017) Development of the Short-Term Life Review Performed by Nurses as Spiritual and Psychological Care for Terminally Ill Cancer Patients. J Pall Car Nur 1(2): 110.
Purpose: The purpose of this study was to develop the Short-Term Life Review (STLR) for performance by nurses as spiritual and psychological care for terminally ill cancer patients.
Methods: Five nurses conducted the STLR. In the STLR, patients review their life, nurses made a simple album, the patient and the nurse confirmed the contents of the album. The nurses recorded comments in interviews. In the analysis, researchers selected themes of narratives, conducted a qualitative analysis of nurses’ comments, and did quantitative analysis for only a completion rate.
Results: Nine of 10 patients completed the study that gave the completion rate of 90%. The themes of the narratives were family, children, human relationships, and enjoyment. These themes supported the professional findings of clinical psychologists. Comments from nurses focused on the benefits of the STLR to patients and nurses.
Conclusion: Based on the high completion rate, narrative themes and comments from nurses, we developed an STLR program that can be performed effectively by nurses.
Keywords: Short-term life review; Terminally ill cancer patients; Spiritual well-being; Nurses; Feasibility
Terminally ill cancer patients experience various mental and psychological problems, including depression, which has a pooled mean prevalence in cancer patients of 8–24% , and psycho-existential suffering . The elderly population is increasing worldwide and the number of elderly people is expected to increase in Japan. Many people will confront psycho-existential suffering before death, which is referred as spiritual pain, and development of psychological care for this pain is an important problem. Narrative therapy  and dignity therapy  are two well-known interventions. However, there is little evidence-based research on narrative therapy, and dignity therapy that can be hard to conduct due to cultural differences.
The life review is another approach to psycho-existential care. Haight  used a structured life review as a form of interview, and several studies have shown the effects of life reviews on depression, self-esteem, and life satisfaction [5–7]. Since terminally ill cancer patients were unable to complete the normal life review, Ando et al.  developed the Short Term Life Review (STLR) and showed that this care was effective for spiritual well-being and psychological distress such as depression or anxiety. The STLR was conducted by clinical psychologists, but such professionals are not always available in every hospital. In contrast, nurses spend considerable time with patients. The Ministry Health, Labor and Welfare in Japan has been trying to promote quality of life for cancer patients, to realize equal and accessibility of care nurses were thought to be adequate. Therefore, wide use of the STLR for many terminally ill cancer patients may require implementation by nurses. In Japan, most of the people do not have particular religion and there are few chaplains or spiritual care workers, and therefore, nurses can also provide spiritual care.
As spiritual care in practice, nurses show empathy and compassion to inspire the will to live; attend to physical, emotional and spiritual needs of patients; listen to fears, worries and reflections and to the patient's spiritual story; help patients to carry out their religious practices; and work together as part of an interdisciplinary healthcare team . Patients want to discuss spirituality with nurses  and nurses say that spirituality is important in their work . For all of these reasons, we hypothesized that nurses may be suitable to conduct the STLR for psychological and spiritual care, but use of such an approach by nurses has not reported. To use the STLR as nursing care, we needed to examine the feasibility, compare themes in narratives with those obtained by clinical psychologists, clarify the best time for nurses to conduct the program, and develop the STLR for nurses. Therefore, the purposes of this study were 1) to examine the feasibility of the STLR, 2) choose themes in narratives by nurses, and 3) evaluate comments and practical issues, with the goal of developing the STLR program to be used by nurses.
The participants were cancer patients from the palliative care units of two general hospitals and five nurses. Table 1 shows the background of the patients and nurses. The age range of nurses was between 20s to 50s, and the mean years of experience as a nurse was 19.8 years (range 6 to 33 years). Two of the nurses were certified in palliative care. All nurses received training for the STLR outside of duty work time and were trained while playing the role. The hospitals were located in a medium-sized city in Japan.
Table 1: Background of terminally ill cancer patients.
The inclusion criteria for patients were (1) incurable cancer of disease stage IV, (2) ≥ 20 years of age, and (3) the primary physician thought that the patient would benefit from the psychological interventions; that is, when the primary physician felt that a patient needed mental support, the physician suggested that the patient could participate in the study. A primary physician or head nurse in each hospital explained the study to the patients who met the inclusion criteria. The only exclusion criterion was cognitive impairment.
Performance status was measured by the Eastern Cooperative Oncology Group Performance Status Rating (ECOGPSR)  from zero to four points. This scale is a widely used measure of functional status. It is a single item rating of five activity levels: 0 = fully active; 1 = restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature; 2 = ambulatory and capable of all self-care but unable to carry out any work activities, up to and more than 50% of waking hours; 3 = capable of only limited self-care, confined to bed or chair more than 50% of waking hours; 4 = completed disabled, cannot carry on any self-care, totally confined to bed or chair.
This study was mainly qualitative study. After obtaining informed consent, nurses conducted the STLR. This intervention consisted of two interview sessions. The duration of the interview was from 30 to 60 minutes. The patients were asked to re-evaluate both good and bad memories. Questions were chosen from our previous study of the STLR (Ando, et al. 2010), in response to which participants gave a narrative . The questions were about 1) the most impressive memories in your life, 2) the most important role in your life, 3) the most important thing in your life. The patients' narratives were recorded. After the first session, the interview was transcribed into verbatim and the researcher made a simple history album using keywords from the answers to each question. Words or phrases used by the patients were written in the album as often as possible; both good and bad things were included, and feelings or reframed thoughts — how he or she feels now — were written in the album. The nurses pasted photos or drawings from books or magazines related to each patient's words or phrases to enhance the album and make it more memory-provoking. The treatment lasted only one week for patients to complete the study. In the second session, the patients confirmed the contents of the history album and discussed their impression of the intervention with the nurses. After the intervention, nurses wrote down their comments on the intervention.
To make a program, we needed to know how nurses perceived the STLR, and then we used qualitative analysis for their comments. Since nurses in this study had experienced in palliative care wards and some had professional certification, so their comments were thought to be reliable. Also, researchers who conducted categorization had certification of a nurse, clinical psychologist, and experience of qualitative analysis, then categorization was thought to be reliable. About saturation, nine patients were suitable for preliminary study about testing feasibility and then we stopped at this stage. Also about categorization to obtain validity and reliability, we received suggestions from other professional researchers of qualitative study and feedback from the nurses who conducted the interviews.
To obtain themes of patients’ narratives, patients narrated their lives based on the three questions above, nurses made albums based on narratives, and the researchers chose themes of the narratives. For comments given during the interview, the researchers conducted qualitative analysis . The researcher read the comments, and chose codes, subcategories and categories from the comments. To maintain reliability and validity, researchers discussed their findings until agreement when there were discrepancies, and also asked nurses who conducted the interviews to confirm the categorization.
A quantitative analysis was also done about the completion rate.
The ethical and scientific validity of this study was approved by the institutional review boards of the St. Mary’s College and all participating institutions.
Ten patients started the study and nine of them completed all parts, giving a completion rate of 90%.
Themes of Narratives of Patients in the STLR
There were three main questions in the STLR upon which patient narratives were based. 1) The themes for “impressive memories” were “Work life”, “Birth of children,”“Growth of children,” “Recreation,” and “Personal encounters”. 2) The themes of “Roles in your life” were “Working,” “Raising,” “Roles in my family,” and “Wishing for my children’s happiness.” 3) The themes for “Important things in your life” were “Family,” “Human relationships in the work place,” “Children,” “Autonomy,” “Human relationships,” and “Belief in his/her life.”
Comments from Nurses on the Practice of the STLR
The comments from nurses on the practice of the STLR were summarized as codes, subcategories, and categories in a qualitative analysis (Table 2). Nurses evaluated the STLR through the patients’ words, such as “Chance to look back at own life” and “Feeling of missing old times”. These subcategories were integrated into 'Benefits for patients'. Nurses also evaluated the STLR from their experiences, such as “Creating a chance to connect deeply with patients”, and “Making use of this connection in future nursing care”. These subcategories were integrated into 'Benefits for nurses'. The STLR was conducted as a team and this led to points such as “Making use of daily human relationships,” “Selection of participants being priority to patients’ benefit”. These subcategories were integrated into 'Contriving points'. Lastly, nurses clarified important points required to conduct the STLR safely, such as “Requirement of sufficient explanation of review” and “Selection of participants”. These comments were integrated into 'Points for consideration'.
Table 2: Quantitative analysis of comments on the STLR.
Feasibility of Performance of the STLR by Nurses
The completion rate of the STLR performed by nurses was 90%. The number of participants differed from that in our previous study, but the withdrawal rate of 10% with nurses was similar to that of 12% with clinical psychologists , indicating the feasibility of the STLR with nurses. The patient who stopped the STLR said that she felt sad remembering certain memories, although the interviewer explained the importance of reminiscence. This suggests that the interview should be stopped in these situations.
The themes of narratives such as “Family”, “Birth of children,” “Working,” or “Human relationships” were similar to those in the study conducted by a clinical psychologist . Nurses completed the STLR in nine patients without problems, and the high completion rate and similar themes of narratives of patients to those with a clinical psychologist suggest the high feasibility of performance of the STLR by nurses. The nurses in this study had rich nursing care experience, and in order to expand the STLR care, more nurses are needed. In addition, the nurses conducted the STLR as research, and use of this approach in daily work might be limited by the time available. Therefore, one of our next studies will be determining how the STLR can be conducted in daily work.
Perception of the STLR by Nurses
As “Benefits for patients,” nurses perceived that patients have “Chance to look back at own life,” “Feeling of missing time,” and “Sorting out their feelings”. These subcategories show the utility of the STLR for terminally ill cancer patients to integrate their lives and have peace of mind. These findings support the theory of identity integration by Erikson . A previous study showed that the life review interview was effective in reducing anxiety symptoms and strengthening positive mental health , and a recent meta-analysis showed that a life review interview group was effective for depression, quality of life and self-esteem, compared to a control group . In addition to these effects, the present study demonstrates other kinds of benefits for patients.
Regarding “Benefits for nurses,” nurses had a chance to connect with patients deeply and utilize this skill in future care. Nurses may talk about patients' life history in care, since there was no life review program for terminally ill cancer patients; therefore, formulation of the program in this study may be significant. Most importantly, nurses found meaning in care through the intervention. This may be related to maturity as a nurse. Hubbell et al.  showed that clinicians who integrate spirituality into their practice appear to be aware of their own spirituality and listen to patients' cues, and Trelor  suggested that the breadth and depth of spiritual care offered reflects the nurses own spiritual maturity. Thus, it is important for nurses to have an attitude of spiritual care and maturity.
Several points of consideration were clarified for conducting the STLR. The subcategory “explanation about the research with sample questions” emphasizes the importance of an explanation of the review, and the interviewer needs to accept patients’ emotions and treat them adequately. Patients with life-threatening illness face challenges from negative emotions such as depression, anxiety, hopelessness, low self-respect and poor quality of life . Life review focuses on both positive and negative life events. When reviewing negative events, patients relive their negative feelings, re-evaluate and integrate experiences, accept the past, and even come to a peaceful state through letting events go and resolving conflict . Thus, expression of negative feelings is useful to integrate patients’ lives. Lastly, based on the high completion rate, narrative themes and comments from nurses for the STLR, we developed a STLR program for nurses (Table 3).
Table 3: The Short Term Life Review (STLR) program for nurses.
The limitations of the study include the small number of patients, which makes it difficult to generalize the results; and two of the five nurses being palliative care-certified nurses, and thus having basic communication training with terminally ill patients. Thus the high rate of feasibility might reflect their basic skills.
Conclusions and Recommendations
We conclude that 1) nurses are able to conduct the Short Term Life Review, 2) there are benefits of the STLR for terminally ill cancer patients for spiritual or psychological care and nurses. Based on that, the researchers recommend training nurses to practice the STLR and confirm its utility, and to conduct an educational program about the use in importance of STLR in the future.
Conflict of Interest
The authors declared that they have no conflict of interest.
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