End-of-life Care in Us Nursing Homes a Review of the Evidence

• Research article
• Open up Access
• Published: 26 June 2021

NUrsing Homes End of Life care Program (NUHELP): developing a circuitous intervention

• Ana Alejandra Esteban-Burgosⁱⁱ,
• Daniel Puente-Fernández ORCID: orcid.org/0000-0002-4917-9078 ³,
• María Paz García-Caro⁴,
• Cesar Hueso-Montoro⁵,
• Raquel Mercedes Herrero-Hahn⁶ &
• Rafael Montoya-Juárez⁴

BMC Palliative Care volume xx, Article number:98 (2021) Cite this commodity

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Abstract

Groundwork

Nursing homes are likely to become increasingly important as cease-of-life care facilities. Previous studies indicate that individuals residing in these facilities have a high prevalence of end-of-life symptoms and a significant need for palliative care. The aim of this report was to develop an end-of-life intendance program for nursing homes in Espana based on previous models nevertheless adjusted to the specific context and the needs of staff in nursing homes in the country.

Methods

A descriptive study of a complex intervention process was developed. The study consisted of three phases. The first stage was a prospective study assessing cocky-efficacy in palliative intendance (using the SEPC scale) and attitudes towards cease-of-life intendance (using the FATCOD-B scale) among nursing home staff before and after the completion of a basic palliative care training program. In the 2d stage, objectives were selected using the Delphi consensus technique, where nursing abode and primary care professionals assessed the relevance, feasibility, and level of attainment of 42 quality standards. In stage 3, interventions were selected for these objectives through ii focus group sessions involving nursing abode, primary care, and palliative care professionals.

Results

As a effect of the grooming, an comeback in self-efficacy and attitudes towards end-of-life care was observed. In phase ii, 14 standards were selected and grouped into 5 objectives: to conduct a comprehensive assessment and develop a personalized intendance plan adapted to the palliative needs detected; to provide information in a clear and attainable mode; to request and tape advance care directives; to provide early intendance with respect to loss and grief; to refer patients to a specialized palliative care unit if appropriate, depending on the complexity of the palliative intendance required. Based on these objectives, the participants in the focus group sessions designed the 22 interventions that make up the programme.

Conclusions

The objectives and interventions of the NUHELP program plant an stop-of-life intendance program which tin can exist implemented in nursing homes to meliorate the quality of end-of-life care in these facilities by modifying their clinical practice, system, and relationship with the health organization besides as serving every bit an instance of an effective health intervention programme.

Peer Review reports

Groundwork

The aging of the population has led to an increase in chronic affliction [1]. To address this state of affairs, institutions such as the World Health System recommend the use of strategies such as palliative intendance, specially amongst people over 65 years of age [one]. Palliative care is interdisciplinary care that focuses on improving the quality of life of individuals of any age living with a life-threatening illness, as well as that of their families [two]. This approach to palliative intendance transcends mere symptom control, although the latter is likewise of paramount importance [one].

Despite being one of the groups that would benefit almost from this arroyo, elderly people receive very niggling palliative care, since this type of intendance has traditionally been aimed at cancer patients and healthcare professionals receive insufficient training in managing comorbidities in this age group [3]. Some other cistron that may lead to reduced access to palliative care for the elderly is the lack of integration between nursing homes and wellness systems in different countries [4].

Indeed, the white paper past the European Clan of Palliative Care [five] and the results reported by the European Stride project (PAlliative Care for older people in care and nursing homes in Europe) [6] emphasize the importance of intervention programs that accept into account specific cultural and organizational contexts and involve participation by the professionals working at the institutions where the interventions are to be implemented.

Nursing homes are likely to become increasingly important as terminate-of-life care facilities. Previous studies betoken that individuals residing in these facilities take a high prevalence of end-of-life symptoms and a significant demand for palliative care [seven,8,9,ten,11,12].

Various projects and interventions have been developed to ameliorate the provision of end-of-life care in nursing homes such as the Aureate Standards Framework for care homes [13, xiv], the Road to Success program [15], or the Namaste programme [sixteen], which is specifically designed for patients with dementia. Recently, the European Footstep project tested the effectiveness of an terminate-of-life intervention plan in nursing homes in vii countries, among which Spain was non included [17].

These intervention programs share several common characteristics. A contempo literature review [18] stresses that, in order to implement end-of-life care interventions in nursing homes, a capacity building approach is needed in add-on to training in palliative care. This approach includes an internal team with effective leadership, back up from an external palliative intendance team, and constant communication between the ii teams regarding specific cases where necessary.

After reviewing the literature on the experiences of nursing abode staff, Commodities et al. (2019) [19] reported that healthcare institutions should facilitate the implementation of interventions in these facilities, while focusing on the needs of staff at all times. Specifically, the authors pointed out that comeback is needed in end-of-life intendance programs in areas such as spirituality, advance directive planning, and family unit involvement.

Members of the Stride project have published a review echoing the about effective strategies for implementing terminate-of-life care programs in nursing homes, highlighting the fundamental role of the particular context, the involvement of the center's ain professionals, and its culture in relation to palliative care [6]. These same points were noted in the white newspaper from the European Association of Palliative Care [5].

In Spain, as in other European countries, a high prevalence of palliative care needs and difficult-to-command symptoms have also been reported in nursing homes [twenty,21,22]. Nonetheless, no palliative care programs specifically focused on this type of facility have been published to appointment [23].

The emergence of the current COVID-xix pandemic has brought to light the shortcomings of the intendance provided in nursing homes. Despite the dramatic numbers of elderly people who take died or been infected in several countries bordering Spain, this crunch may represent an opportunity to develop a better model of care in these institutions [24]. This model of care must strike a residual betwixt disease prevention and a more humane approach that addresses the psychosocial needs of the elderly [25]. Palliative care is an essential part of this approach. Nonetheless, a recent review [26] has noted that, although a wide range of recommendations for preventing and treating patients with COVID-19 in nursing homes take been published, few homes have taken the fourth dimension to address the main recommendations regarding palliative intendance needs.

The aim of this report was to develop an end-of-life care programme for nursing homes in Kingdom of spain based on previous models yet adapted to the specific context and the needs of staff in nursing homes in the country. The specific objectives for each stage were:

• Phase ane: To increment cocky-efficacy in palliative care and improve attitudes toward end-of-life care among professionals working in the participating nursing homes.

• Phase 2: To select objectives that are relevant, viable, and capable of generating changes in cease-of-life care in nursing homes.

• Phase 3: To select the most suitable intervention to achieve each objective based on the experience of each establishment.

Methods

Context and target population

The program was developed for 8 Andalusian nursing homes which were selected based on their institutional characteristics. Nursing homes in Spain offering all-inclusive accommodation to dependent individuals on a temporary or permanent basis. The objectives of this type of facility are to ameliorate residents' quality of life and promote their individual autonomy through the provision of intervention programs and activities tailored to their specific needs [27]. They all had more 60 beds and were privately funded. In Kingdom of spain, at that place were a full of 3844 private nursing homes (71.53 %) in 2017. Private institutions commonly offering a number of beds in conjunction with the public wellness system [28]. Circuitous intendance services are offered depending on the number of beds. Nursing homes with more than 60 beds are required to offer 24-hour nursing services and their own medical intendance [29]. The public, universal nature of healthcare in Kingdom of spain means that every nursing dwelling is supervised by a primary care squad (a medico and a nurse) depending on the geographic area in which the nursing home is located. Each nursing home has its ain contracted professionals (a physical therapist, a psychologist, an occupational therapist, a social worker, a nursing assistant, and nurses) and a principal care team assigned by the public health system.

To select the nursing homes included in this report, a list of facilities meeting the inclusion criteria (i.e. presence of a multidisciplinary squad, professionals interested in participating in the written report, and the availability of public and individual beds) was requested from the primary care district in the public wellness organisation. Each facility was then contacted and an interview was arranged to inform them nigh the project. Finally, the nursing homes that agreed to carry out the intervention program were included in the study.

Intervention development approach

The intendance program to be developed as role of this study may be described as a circuitous intervention as information technology is fabricated upward of diverse interacting components. Complication may exist caused past the presence of several potential outcomes, variability in the target population, or a number of elements in the intervention package itself [30, 31]. The intervention program to be adult must focus on multiple populations (professionals, family members, residents) and may have a large number of potential components and issue variables.

This study addresses many aspects of the development phase of a circuitous intervention, including the exploration of relevant frameworks, identification of existing evidence, exploration of potential intervention components, and modeling of the intervention components [thirty, 31]. The implementation process has already begun and will be described in subsequent studies. The development process combines both qualitative and quantitative methods, as proposed in similar settings [31, 32].

In addition, recommendations from specific literature reviews on interventions in nursing homes have been followed, equally explained in the introduction [six, 18, xix].

The evolution of the program can exist divided into three phases. The blueprint, participants, and methodology of each of the three phases are shown below. A summary of the methodology, the participants, and the primary outcomes of each phase is shown in Table 1. The study was canonical by the Enquiry Ethics Committee "Comités de Ética Asistencial Granada Metropolitano" for the Andalusian Public Health System with reference number (0706-Northward-17).

Table 1 Summary of the objectives and methodology of the different phases in the NUHELP program

Full size table

Stage 1: Palliative care preparation in participating nursing homes

Design of the stage 1

Following the recommendations fabricated past Hockley et al. [33], basic training in palliative care was provided to nursing home staff. The design of this phase was a prospective study assessing the efficacy of the training delivered. The effectiveness of the training program was assessed pre/mail service intervention.

Participants

The training was intended for professionals from the nursing homes participating in the project (physicians, nurses, social workers, psychologists, concrete therapists, and occupational therapists).

Data collection

The 50-hour online training course was taught by professionals from the University of Granada, Spain, and the Andalusian Public Health Organization betwixt September 2017 and January 2018. The online form contained 7 modules featuring scientific literature, presentations, videos, case studies, and a discussion forum. Earlier passing a module and moving on to the next, participants had to laissez passer an exam and consummate a number of activities. The form was open up for completion for 5 months. The course was accredited past the Continuous Training Commission of the Spanish National Health Organisation and the Andalusian Agency for Healthcare Quality. The training included:

1. i.

   Full general aspects of palliative care, models of care, and identification of palliative care needs.

2. 2.

   Principles of symptom control and comfort care. Comprehensive assessment and pain control.

3. 3.

   Monitoring of nutrition, excretion, activity/rest, and cerebral symptoms.

4. 4.

   Psychosocial intendance in palliative care.

5. five.

   Peri-death care, emergency care, and special finish-of-life situations.

6. half-dozen.

   Communication and decision-making.

7. seven.

   Grief intendance and burnout prevention in healthcare professionals.

Instruments

Changes in perceptions of efficacy among the professionals themselves were assessed using the Self-Efficacy in Palliative Care (SEPC) scale [34]. This scale is based on the theoretical principles of Bandura'due south Social Cognitive Theory [35] and consists of 23 items that appraise perceived efficacy in relation to communication (8 items), patient direction (viii items), and multiprofessional teamworking (7 items). Each behavior or skill was assessed using a 100 mm visual counterpart calibration ranging from "very anxious" to "very confident." The reliability and validity of the Spanish version of the calibration were adamant for nursing professionals and students, yielding a Cronbach'due south α value greater than 0.944 on all subscales [36].

Changes in attitudes towards end-of-life care were assessed using the FATCOD scale, designed past Frommelt in 1991 [37] to evaluate nurses' attitudes towards the intendance of terminally sick patients and their families. A new version (FATCOD-B) was subsequently adult past the same writer in 2003, allowing the scale to exist used among different healthcare professionals [38]. The FATCOD-B calibration showed an inter-rater agreement of i.00 and a Pearson'southward exam-retest of 0.9269. The scale consists of xxx items rated on a five-point Likert scale, 15 of which are reversely worded.

Data analysis

The SEPC and FATCOD-B scales were administered at the showtime and cease of the grooming course. To assess the changes produced by the intervention, non-parametric tests were performed (Wilcoxon's test for related samples) and statistical results were shown in terms of median and interquartile range. The magnitude of the effect was also calculated for each of the dimensions related to the preparation course.

Phase 2: Selection of the objectives.

Design

The objectives were selected using an adaptation of the Delphi consensus technique.

Participants

Five professionals from each nursing home who had completed the training course in the previous phase, also as professionals (a physician and a nurse) from the referral master care centers for each nursing home were selected.

Data collection

Each standard was assessed based on three dimensions: its relevance to the nursing home setting; the feasibility of its implementation; and its level of attainment in each nursing dwelling. Each dimension was rated on a Likert scale with options ranging from ane (not at all) to five (absolutely). Two consecutive Delphi rounds were held. Between the two rounds, each participant was provided with a summary of the responses of all participants, in addition to their own previous responses.

Instruments

As a starting indicate, 42 standards that could be applicable to nursing homes were selected from Finish of Life Care for Adults by the British National Institute for Health and Intendance Excellence, Prissy [39], and the New Health Foundation [40]. A native Castilian translator translated them into Spanish and another translator translated them back into English in lodge to ensure that the original pregnant was preserved.

Information analysis

The objectives were selected using a cascading model by applying the criteria in a consecutive manner, as shown in Fig. i. For the dimensions of relevance and feasibility, the standards selected were those rated equally iv or 5 past 70 % of the participants. This level of agreement was approved by the research team prior to the start of the Delphi grouping [41]. Given that ane of the specific objectives of this study was to develop an intervention programme that would generate changes to end-of-life intendance in nursing homes, the standards selected were those that did non exceed lxx % of the sum of iv and 5 s with regard to the level of attainment in each nursing home. Due to the lack of formal records on most of the aspects to be evaluated, the evaluation was carried out using subjective, individual assessments from the professionals. Finally, some of the standards selected were merged with one some other in view of their similarity and were worded in such a way as to make them attainable.

Phase iii: Selection of the interventions

Design

Consecutive focus group sessions with professionals from participating nursing homes.

Participants

The post-obit individuals participated in this stage: one representative of the professionals from each nursing home, one representative of the referral main care centers for the nursing homes, the coordinators of the nursing homes in the districts of Granada and Jaén, and physicians specializing in palliative care. In total, 25 professionals participated (8 from nursing homes, 8 from primary care centers, four nursing dwelling coordinators, and v researchers).

Data drove

Based on the objectives selected in phase two, focus groups of five participants were established. In the focus grouping sessions for objectives 1–iv (assessment, data, grief, and emotion direction), two nursing home professionals and 2 primary intendance professionals participated. Given the complexity of objective 5 (referral), it was assigned to the nursing abode coordinators and palliative care physicians. One researcher would act as the moderator and record the relevant data in each focus grouping session. Two sessions were held for each focus grouping, with a duration of approximately one hour.

During the first session, in October 2018, the professionals discussed the interventions that were being implemented in their centers, the outcomes they had attained, the difficulties they had encountered, and how they had overcome them.

To facilitate consensus-building on the interventions to be implemented, participants were provided with 2 documents one week prior to the first session: (i) one international literature review of interventions implemented in nursing homes for each of the objectives proposed and (2) a report on the interventions carried out in the participating centers for each of the objectives, which had been nerveless previously via an online form.

After the transcripts had been analyzed, the proposals for each objective were synthesized and sent dorsum to the members of each group.

In the second session, held in May 2019, the proposals agreed upon in session one were discussed in guild to adapt them to the clinical reality of the nursing homes in the study. The script of the two sessions is shown in Tabular array 2.

Table 2 Script for focus grouping sessions

Full size table

After the focus group sessions were held, the researchers synthesized the proposals made and forwarded them to the participants in each group for final approval. This commodity focuses on the interventions that were finally selected.

Ethical considerations

This written report complies with the bones upstanding principles governing responsible conduct in research involving human subjects. Informed consent was sought from all participants. The study was approved by the Research Ethics Committee (0706-North-17). The patients' data were anonymized in compliance with Spanish regulations.

Results/findings

Phase 1: Training

Fifty-ii professionals from the nursing homes received the training, of which 27 were nurses (51.ix %), 7 were occupational therapists (13.vi %), 6 were psychologists (11.five %), v were social workers (9.6 %), five were physical therapists (9.six %), and 2 were physicians (3.8 %). An increase in all variables was observed post-obit the grooming, both for the FATCOD-B and SEPC scales and for the different subscales of the SEPC scale (teamwork, communication, and psychosocial/spiritual and physical aspects of patient management). Effect sizes of 0.710 and i.5 were observed for the total scores on the SEPC and FATCOD-B scales, respectively. The results of the training course is shown in Table 3.

Table 3 Results of the preparation course

Full size table

Phase ii: Selection of the objectives

For the selection of the objectives, 40 professionals from the participating nursing homes who had completed the training course in the previous phase were contacted (5 professionals per centre). Referral primary care physicians and nurses for each nursing home were also contacted (16 in full). In total, 52 participants responded, with 38 and fourteen participants from each group respectively (response rate = 93 %).

On the footing of the established criteria, the professionals from the nursing homes considered the 42 initial standards to be relevant, but just 28 of them were considered to be feasible. Of these, fourteen were considered to have a low level of attainment in the participating centers. The scores given by nursing habitation professionals to the standards for each dimension in the last Delphi circular are shown every bit Supplementary Material 1. Finally, the 14 standards were reworded and merged into 5 objectives in view of their similarity. The 5 objectives were as follows: "To conduct a comprehensive assessment and develop a personalized intendance plan adjusted to the palliative needs detected", "To provide information in a clear and accessible manner", "To asking and record advance care directives", "To provide early intendance with respect to loss and grief", and "To refer patients to a specialized palliative care unit if appropriate, depending on the complexity of the palliative care required".

Phase iii: Selection of the interventions

The interventions proposed were discussed in the focus grouping sessions. Following these discussions, the participants selected 22 interventions, which are shown in Table 4. Some interventions were described as optional past the participants, since their implementation depended on residents displaying sure characteristics. An example of an intervention is shown in supplementary material 2.

Table 4 Relationships between the standards, objectives, and interventions in the NUHELP program

Full size tabular array

Discussion

This newspaper shows the development of a complex intervention: an end-of-life care programme for patients in Spanish nursing homes. The NUHELP program has been shaped and adapted to this context in accord with previous models, based on communication from primary intendance professionals responsible for the care provided at the participating nursing homes and designed to run into the needs of professionals at the homes. It is worth noting that this is the commencement terminate-of-life intervention program developed in nursing homes in Spain. Eleven out of the 42 preexisting palliative care standards were selected and grouped into 5 objectives, for which 22 interventions were created.

Firstly, a cadre chemical element in the evolution of the plan was grooming at nursing homes, which was intended to increase self-efficacy in palliative care and improve the attitudes of nursing home professionals towards finish-of-life care. As noted by Honinx et al. [42], for interventions to exist successful, it is necessary to improve the training of nursing habitation professionals in palliative care. The project Stride [43] concluded that greater efforts were needed to increase understanding of palliative intendance in these institutions, albeit with different preparation strategies required depending on the country.

In line with our initial hypothesis, following the palliative care preparation form delivered to multidisciplinary teams at the nursing homes, an improvement in their efficacy in terms of communication, direction, and multidisciplinary teamwork was observed, as well as an improvement in their attitudes towards stop-of-life care. Our results corroborate those of other studies, which conclude that grooming in nursing homes improves non only end-of-life competencies, just also attitudes towards end-of-life intendance, showing an effect size with a large magnitude for both competencies and attitudes [44, 45].

In addition, the choice process using the Delphi technique yielded 11 of the 42 preexisting standards that were reworded and merged together into 5 program objectives. In order to select them, the relevance of the standards, their feasibility, and their level of attainment based on the resources of each nursing dwelling house were taken into account. Being aware of the limitations of a particular setting is key to ensuring the success of a complex intervention such as this, as recommended in recently published reviews [19].

Among all the standards that the professionals rated as feasible, the standards that had a low level of attainment at the centers were chosen. Some of the objectives selected had already been identified in previous studies, while others reflect the unique characteristics of nursing homes in Spain.

Regarding the first objective selected, "to conduct a comprehensive cess and develop a personalized care plan adapted to the palliative needs detected", a proper cess of palliative needs and individualized intendance planning is the basis for successful interventions. Previous studies show that comprehensive cess of older adults improves their functional status and reduces the number of hospitalizations and length of hospital stays [46]. This is because potential complications that may be developing in frail, older individuals are detected earlier [47]. Similar results were observed in Spanish nursing homes where comprehensive geriatric assessment, amongst other factors, made it possible to reduce infirmary and emergency room visits in institutionalized patients and to optimize pharmacy costs [48].

Of the five objectives of the NUHELP program, both the 2nd objective ("to provide information in a articulate and attainable way") and the 3rd objective ("to request and record advance intendance directives") are linked to information and decision-making. Highlighting end-of-life information as an area for improvement in nursing homes [49] is expected to facilitate professionals' end-of-life conversations with residents and family members in a proactive manner, as well every bit address unavoidable decisions in accordance with residents' wishes and needs [50].

As a effect, the third objective of the NUHELP program focused on developing specific programs to help implement advance care directives in nursing homes. These programs focus not only on discussing specific clinical or treatment issues, only as well on discussing patients' values, beliefs, and goals with the patients themselves and their families in club to assistance with clinical decision-making in the event that the patient is unable to brand these decisions on their ain [51,52,53,54].

The fourth objective of the NUHELP program proposes "to provide early on care with respect to loss and grief". Several factors highlight the importance of dealing with anticipatory grief in nursing homes: ambivalence between caregivers' desire to take a pause from caring for the patient, the desire to avoid their decease, and emotional dependence on the patient tin pb to subsequent grief complications [55]. Acceptance of death past both parties tin aid prioritize decision-making, prioritize patient condolement over longevity, and assist family members bargain with the subsequent loss [56, 57]. Improved family communication can also make it easier to say goodbye to loved ones [55]. This is why the NUHELP program includes interventions to improve family members' involvement in the daily care of institutionalized patients.

Spiritual and religious support for individuals approaching the terminate of their lives and their families was besides considered a priority intervention for this objective. Proper management of this dimension may amend wellbeing and relieve pain and other symptoms [58], highlighting the need for correct identification of needs in this area. It has been noted that improved admission to religious services offered past many nursing homes can assist to meet the spiritual needs of their residents [59]. As for specific interventions to improve spirituality, there are a small number of clinical trials on interventions in spirituality, and the studies published are extremely heterogeneous [60].

The fifth and final objective of the NUHELP programme is "to refer patients to a specialized palliative care unit if advisable, depending on the complication of the palliative care required". Referring patients from nursing homes to specialized palliative care services, even if the resident remains in the nursing dwelling house (specialist palliative intendance consultations), is expected to reduce the number of hospitalizations and visits by emergency intendance teams [61]. According to a recent review [62], timely identification of the patients who would do good most from these services in nursing home stop-of-life care programs would improve referral when needed and encourage appropriate use of bachelor resources.

Moreover, given the heterogeneity of the resources for end-of-life care available at each nursing dwelling house, each establishment needs to assess the circumstances in which it would refer patients requiring complex intendance. The NUHELP programme includes this intervention inside objective 5.

The results of this study provide an example of the creation of a complex, comprehensive intervention programme for Spanish nursing homes past highlighting their weather, strengths, and needs and addressing them through a set of interventions aimed at providing high-quality bones care and enhancing coordination with the public wellness system.

Among the limitations of the present study, it should be noted that the selection of the centers and participants throughout the dissimilar phases could not be randomized. As a event, it is probable that the nursing homes and professionals involved were the most motivated to participate. Furthermore, although the literature indicates that all nursing homes in Spain could do good from this plan, it has been specifically designed by the participating nursing homes and adapted to their particular characteristics, so circumspection should be exercised when extrapolating results.

Conclusions

The NUHELP program has been developed using a combination of quantitative and qualitative methods. 22 interventions were selected to enable the attainment of the 5 objectives in the intervention program and amend cease-of-life care at these centers.

This intervention programme aimed to improve the basic palliative intendance provided at the different nursing homes past modifying their clinical and organizational exercise too equally their relationship with the public health organization, presenting palliative intendance as a necessity at these centers and providing tools for successful palliative intendance commitment. The NUHELP plan could also exist used equally an instance of complex intervention development when designing other programs at nursing homes or other types of facilities.

Availability of data and materials

The datasets during and/or analyzed during the current written report available from the corresponding author on reasonable asking.

Abbreviations

SEPC:

Cocky-Efficacy in Palliative Care

FATCOD-B:

Frommelt Attitudes Toward Care of the Dying Scale Form B

NUHELP:

NUrsing Homes Terminate-of-Life care Program

PACE:

PAlliative Care for older people in care and nursing homes in Europe

COVID-19:

coronavirus disease 2019

NICE:

British National Institute for Wellness and Care Excellence.

IQR:

interquartile range

Me:

median

R:

range

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Acknowledgements

We would like to thank all professionals and to all nursing homes and primary care centers who made this study possible.

Funding

This study has been totally funded by Consejería de Salud, Junta de Andalucía (Fundación Pública Andaluza Progreso y Salud, Proyecto AP-0105-2016). Funding has been received for data collection, analysis and interpretation of data and manuscript writing.

Author information

Affiliations

1. Salvador Caballero Primary Care Middle, Andalusian Health Service, Granada, Spain

   Emilio Mota-Romero

2. Department of Nursing, Doctoral Program in Clinical Medicine and Public Health, University of Granada, Granada, Spain

   Ana Alejandra Esteban-Burgos

3. Doctoral Plan in Clinical Medicine and Public Wellness, University of Granada, Granada, Spain

   Daniel Puente-Fernández

4. Section of Nursing, Brain and Behaviour Inquiry Constitute, University of Granada, Listen, Spain

   María Paz García-Caro & Rafael Montoya-Juárez

5. Section of Nursing, University of Granada, Granada, Spain

   Cesar Hueso-Montoro

6. University Health Provider Establishment, Academy of Antioquia, Medellín, Republic of colombia

   Raquel Mercedes Herrero-Hahn

Contributions

EM, DP, MG, CH and RM have participated in the study desing. EM, AE, DP, MG, CH, RH and RM have participated in participant recruitment, conquering of data and data entry. EM, AE, DP, MG, CH, RH and RM have participated in the analysis, estimation of data and final manuscript drafting. The writer(due south) read and approved the last manuscript.

Corresponding author

Correspondence to Daniel Puente-Fernández.

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Ideals approval and consent to participate

This written report complies with the basic ethical principles governing responsible carry in research involving human subjects. Written informed consent was sought from all participants. The written report was canonical by the Research Ideals Committee "Comités de Ética Asistencial Granada Metropolitano" of Andalusian Public Health System with reference number (0706-N-17). The patients' data were anonymized in compliance with Spanish regulations.

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Non applicable.

Competing interests

The authors declare that they have no competing interests.

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Mota-Romero, E., Esteban-Burgos, A.A., Puente-Fernández, D. et al. NUrsing Homes Finish of Life care Program (NUHELP): developing a complex intervention. BMC Palliat Care 20, 98 (2021). https://doi.org/x.1186/s12904-021-00788-1

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• Received: 23 Nov 2020

• Accustomed: 04 June 2021

• Published: 26 June 2021

• DOI : https://doi.org/10.1186/s12904-021-00788-1

Keywords

• Nursing Habitation Care
• Finish of Life
• Holistic Care
• Nurse-Patient interaction
• Nurse-Patient Relationships
• Older People
• Palliative Care

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