Background ENABLE (Educate, Nurture, Advise, Before Life Ends) is a nurse coach-led, early palliative care model for patients with advanced cancer and their family caregivers. Content covered includes problem-solving, advance care planning, symptom management and self-care. The aim was to evaluate the cultural acceptability of ENABLE among patients with advanced cancer and their caregivers in Singapore and identify modifications for an adapted ENABLE-SG model. Methods Qualitative formative evaluation with a thematic analysis approach in two hospitals in Singapore, involving patients (n = 10), family caregivers (n = 11) and healthcare professionals (n = 10) who care for patients with advanced cancer. Semi-structured interviews were conducted to explore (i) the main needs and challenges facing individuals with advanced cancer and their family caregivers; (ii) patient involvement in healthcare decision making; and (iii) content and delivery of ENABLE. Results While physical needs were largely well met, participants expressed that psychosocial care was delivered too late in the illness trajectory. Healthcare decision making approaches varied from a patient-centred shared decision-making model to a family-centred model where patients may not know their cancer diagnosis and prognosis. The content was considered to be relevant, comprehensive and practical; financial assistance, adjustment to body image, and evaluation of complementary therapy were also recommended. Face-to-face rather than telephone sessions were preferred to facilitate rapport building. Conclusions ENABLE was broadly acceptable with some modifications, including adjusting the content to ensure it can be delivered even if the patient is not fully aware of cancer diagnosis and delivering the first session face-to-face with flexibility for subsequent sessions.

ObjectiveTo define clinical empathy from the perspective of healthcare workers and patients from a multicultural setting.DesignGrounded theory approach using focus group discussions.SettingA health cluster in Singapore consisting of an acute hospital, a community hospital, ambulatory care teams, a medical school and a nursing school.Participants69 participants including doctors, nurses, medical students, nursing students, patients and allied health workers.Main outcome measuresA robust definition of clinical empathy.ResultsThe construct of clinical empathy is consistent across doctors, nurses, students, allied health and students. Medical empathy consists of an inner sense of empathy (imaginative, affective and cognitive), empathy behaviour (genuine concern and empathic communication) and a sense of connection (trust and rapport). This construct of clinical empathy is similar to definitions by neuroscientists but challenges a common definition of clinical empathy as a cognitive process with emotional detachment.ConclusionsThis paper has defined clinical empathy as ‘a sense of connection between the healthcare worker and the patient as a result of perspective taking arising from imaginative, affective and cognitive processes, which are expressed through behaviours and good communication skills that convey genuine concern’. A clear and multidimensional definition of clinical empathy will improve future education and research efforts in the application and impact of clinical empathy.

Background COVID-19 is an infectious disease caused by the SARS-CoV-2 virus that has caused substantial impact on population health, healthcare, and social and economic systems around the world. Several vaccines have been developed to control the pandemic with varying effectiveness and safety profiles. One of the biggest obstacles to implementing successful vaccination programmes is vaccine hesitancy stemming from concerns about effectiveness and safety. This review aims to identify the factors influencing COVID-19 vaccine hesitancy and acceptance and to organize the factors using the social ecological framework. Methods We adopted the five-stage methodological framework developed by Arksey and O’Malley to guide this scoping review. Selection criteria was based on the PICo (Population, Phenomenon of interest and Context) framework. Factors associated with acceptance and hesitancy were grouped into the following: intrapersonal, interpersonal, institutional, community, and public policy factors using the social ecological framework. Results Fifty-one studies fulfilled this review’s inclusion criteria. Most studies were conducted in Europe and North America, followed by Asia and the Middle East. COVID-19 vaccine acceptance and hesitancy rates varied across countries. Some common demographic factors associated with hesitancy were younger age, being female, having lower than college education, and having a lower income level. Most of the barriers and facilitators to acceptance of the COVID-19 vaccines were intrapersonal factors, such as personal characteristics and preferences, concerns with COVID-19 vaccines, history/perception of general vaccination, and knowledge of COVID-19 and health. The remaining interpersonal, institution, community, and public policy factors were grouped into factors identified as barriers and facilitators. Conclusion Our review identified barriers and facilitators of vaccine acceptance and hesitancy and organised them using the social ecological framework. While some barriers and facilitators such as vaccine safety are universal, differentiated barriers might exist for different target groups, which need to be understood if they are to be addressed to maximize vaccine acceptance.

Background While older age is associated with better emotional well-being, it is unclear whether such age advantages remain during a pandemic. This study examined differences in mental health, adaptive behaviours, social support, perceived stress, digital media usage, and perceived change in circumstances between younger and older adults during the circuit breaker period (partial lockdown) in Singapore. Methods A door-to-door survey was administered to a nationally representative sample of 602 younger (n = 302) and older (n = 300) adults aged 21–89 years from Singapore from 17 October to 27 November 2020. All participants self-reported their depression, anxiety, stress, adaptive behaviours, social support, perceived stress, change in circumstances, and digital media usage during the partial lockdown period. Results Older adults were found to report significantly lower levels of depression, anxiety, and stress as compared to younger adults. Although older adults were less able to perform essential activities during the lockdown, they were more adaptable psycho-socially. Logistic regression analyses revealed that for older age group, adaptability and health status significantly predicted better mental health. Older adults had higher odds of low depression scores [odds ratio (OR) 1.81, 95% confidence intervals (CI) 1.07–3.08], anxiety scores (OR 1.80, 95% CI 1.05–3.08), and stress scores (OR 3.05, 95% CI 1.72–5.41). In addition, adaptability was found to moderate the relationship between age and mental health with detrimental effects of low adaptability stronger for younger adults than older adults. Conclusions During the lockdown period, older adults in Singapore had better mental health, perceived less stress-related concerns and were more adaptable psycho-socially as compared to younger adults. This study’s findings extend current evidence that age-related advantages in emotional well-being persisted in the wake of the COVID-19 pandemic.

Introduction: The COVID-19 pandemic has brought about multiple losses to various groups, namely patients, families and healthcare professionals. Grief, which is the reaction to these losses, could cause strain on these individuals’ physical and mental health if not identified and managed early. This scoping review analysed loss, grief and how they were managed among these groups during the pandemic. Method: This scoping review utilised the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement extension for Scoping Reviews (PRISMA-ScR) and the Joanna Briggs Institute framework for scoping reviews. Only qualitative studies relating to loss and grief and their management were included. Of 166 studies screened, 69 were included in the study. Qualitative analysis and data coding of each record were conducted through qualitative data analysis software. Results: Losses included the death of family members, patients, colleagues and others. They also included the loss of usual routines, lifestyles and physical health. The grief experienced was multidimensional, affecting mainly the emotional, physical, social and existential realms. Anger, guilt and fear resulted from unsatisfactory farewells, issues with funerals, social isolation, financial strain and stigmatisation. Management strategies could be categorised into 5 themes: communication, finance, counselling, education and spiritual care. Conclusion: Loss and grief identification and management among patients, family members and healthcare professionals are critically important during this COVID-19 pandemic. Current operating guidelines have proven insufficient in managing loss and grief. Innovative strategies are essential to tackle the many dimensions of loss and grief. Nevertheless, further research is necessary to better understand the effectiveness of implemented policies. Keywords: Bereavement, death, mourning, outbreak, palliative care

Background Healthcare professionals’ empathetic behaviors have been known to lead to higher satisfaction levels and produce better health outcomes for patients. However, empathy could decrease over time especially during training and clinical practice. This study explored factors that contributed to the development of empathy in the healthcare setting. Findings could be used to improve the effectiveness and sustainability of empathy training. Method A qualitative approach, informed by aspects of grounded theory, was utilized to identify factors that enabled the development of empathy from the perspectives of doctors, nurses, allied healthcare workers and students. Twelve sessions of focus group discussions were conducted with 60 participants from two hospitals, a medical school, and a nursing school. Data was analyzed independently by three investigators who later corroborated to refine the codes, subthemes, and themes. Factors which influence the development of empathy were identified and categorized. This formed the basis of the creation of a tentative theory of empathy development for the healthcare setting. Results The authors identified various personal (e.g. inherent characteristics, physiological and mental states, professional identity) and external (e.g. work environment, life experience, situational stressors) factors that affected the development of empathy. These could be further categorized into three groups based on the stability of their impact on the individuals’ empathy state, contributed by high, medium, or low stability factors. Findings suggest empathy is more trait-like and stable in nature but is also susceptible to fluctuation depending on the circumstances faced by healthcare professionals. Interventions targeting medium and low stability factors could potentially promote the development of empathy in the clinical setting. Conclusions Understanding factors that impact the development of empathy allows us to develop measures that could be implemented during training or at the workplace leading to improve the quality of care and higher clinical work satisfaction.

BackgroundStigmatisation, misinformation and discrimination have been magnified globally due to the COVID-19 pandemic. The healthcare sector was not spared from this. We conducted a transnational study, using the Health Stigma and Discrimination framework (HSDF) to explore public perception and reactions to the COVID-19 pandemic in a multicultural context. Findings from the Asian arm of the study, sited in Singapore, are reported in this paper.MethodsThis phenomenological research deployed semi-structured informant interviews using non-probability sampling approaches to recruit members of the public. Interviews were coded independently by two researchers and thematic analysis was used to analyse the responses.ResultsTwenty-nine members of the public (23–80 years old) were interviewed between Oct 2020 to Feb 2021. Five major themes were identified: (i) perception of stigma amongst respondents, (ii) experiences of stigma amongst respondents, (iii) views on what drove stigma and misinformation, (iv) facilitators in preventing and reducing stigma and misinformation, and (v) ageist attitudes towards older adults. Overall, construction workers living in dormitories, healthcare workers, and to some extent tourists from China, were perceived to have been stigmatised and shunned by the public. Place-based stigmatisation was common; participants responded by avoiding places that had confirmed cases of COVID-19. Perceived stigma was temporary and not enduring, driven at the outset by fear of being infected. This study also identified the role played by trust in reducing stigmatisation. The relative absence of politicising of issues and high-quality information readily disseminated to the public were reported as factors that could have reduced and prevented stigma and misinformation on the various groups. Ageist attitudes were observed in some participants with older adults being labelled as vulnerable, susceptible to misinformation and being less able to cope during the pandemic.ConclusionThrough the lens of the HSDF, this study provided an exploratory account of the nature of stigma that resulted from the COVID-19 pandemic in an Asian context. It also shed light on facilitators in preventing and reducing stigma during an outbreak especially the role of trust and communications during a public health crisis.

Background Transiting into the community setting often presents novel difficulties for nurses because the role demands skills that might not have been obtained through usual clinical experience or training. The Ageing-in-Place Community Care Team (AIP-CCT) Community Nurse Basic Training programme was developed to address this learning gap. This training programme prepares nurses to lead in a multi-disciplinary team in delivering patient-centred care to patients with progressive or life-limiting conditions in the community setting. This study evaluated the inaugural training programme provided to a group of nurses from an acute hospital in Singapore. Methods Qualitative in-depth interviews were carried out with 13 participants from the training programme three-months after completion of the AIP-CCT Community Nurse Basic Training programme provided by an acute hospital to understand the programme’s impact on their knowledge, skills and clinical practice, as well as barriers and facilitators to learning. Results Overall, perception towards the training course was mixed. Course content was found to be relevant, and participants reported that training led to improvement in their practice. However, experienced nurses felt that the content of some modules were lacking in depth. This could have explained why only junior nurses tended to hold favourable attitudes and felt that the training led to increase in their confidence level. Although medical content was assessed favourably, the course was not able to address some of the constraints faced by community nurses such as managing expectations and handling difficult patients in the home care setting. For some modules, face-to-face training was preferred and e-learning components can be improved to increase communication and interaction. Conclusion This study provided insights into how a community nurse training programme could be developed to meet the needs of community nurses. The training was able to reinforce skills and knowledge, address knowledge gaps and provide new clinical care approaches and communication strategies. These incremental effects on experienced community nurses could be extrapolated to have greater benefits for inexperienced community nurses. Based on findings of the study, potential changes to the training programme were discussed to improve training outcomes.