Healthcare professionals' perceptions of psychosocial support for family members in palliative care inpatient units—A qualitative descriptive study

Abstract Aim This study aimed to describe the psychosocial support healthcare professionals in specialist palliative inpatient units provide to family members of palliative care patients. Design A qualitative descriptive design. Method The data were collected with focus group interviews and analysed with inductive content analysis. Results Altogether, 48 healthcare professionals, including physicians, registered nurses and practical nurses, participated in the study. Information sharing was recognised as an essential element of support. Methods to improve support of family members included an opportunity to allocate recourses to the families, systematic support and strengthening healthcare professionals' competence in family care. The healthcare professionals describe their perceptions of psychosocial support for family members primarily through patient care and the patient's situation rather than family needs. Direct support for the family members is realised principally by information sharing and conversations. Healthcare professionals express their opportunities to implement support focusing on family members' needs restricted by reason of organisational resources. The information can be used when developing and improving family care in palliative care context to recognise the most relevant needs from healthcare professionals' perspective and also when implementing healthcare professionals' education and training.


| INTRODUC TI ON
Palliative care influences millions of people annually, including patients' family members (Connor, 2020). Family support is an indispensable part of palliative care provision, which intends to consider and care for the family members' needs (Steele & Davies, 2015). Support for family members is often implemented primarily through psychosocial support, which typically aims to not only answer the family members' psychological, emotional, informational, social, cultural and spiritual needs, but it can also involve practical support (Macleod, 2008).
Healthcare professionals play an essential role in supporting family members of palliative care patients (LaValley, 2018). That is particularly evident in hospital care, where family members value the professional and safe care of the patient; they expect support from the healthcare professionals, including empathy, compassion, involvement in the care and privacy about their personal space (Virdun et al., 2017). However, families are not always sufficiently considered when implementing palliative care services, and their needs are not recognised enough (Areia et al., 2019). Family members have numerous unmet needs concerning their own coping (Ullrich et al., 2021;Wang et al., 2018), and their need for support can be even higher than patients themselves, especially in inpatient care (Oechsle et al., 2019).

| BACKG ROU N D
Family members need support in palliative care, especially during the patients' hospital periods, and the hospital environment even increases their support needs (Lee & Cha, 2017). Although family members' needs are often related to their coping (Ullrich et al., 2021) and psychosocial needs, the need for various services has also been described (Wang et al., 2018). Additionally, family members require support from healthcare professionals to attend to patient care and be present in the care unit (Saarinen et al., 2021;Soikkeli-Jalonen et al., 2021). The chance to participate in care activities is important to family members, and it is an essential element of family members' experience of support (Virdun et al., 2017). Furthermore, appropriate information sharing about a patient's diagnosis and impending death has been found to benefit family members (Røen et al., 2019).
Moreover, bereavement support organised after a patient's death is found to be beneficial in helping with family members' grief management and ability to cope psychologically (Kustanti et al., 2021).
Supporting family members living in a distressing situation is complex, and improving family members' well-being can be challenging (Saarinen et al., 2021;Soikkeli-Jalonen et al., 2021). In addition, the physical care environment, culture and attitudes towards the family members in the care unit may enhance or hinder support (Partanen et al., 2018). When the care environment is experienced as positive, it can enhance family members' feeling of being supported by the healthcare professionals (Saarinen et al., 2021;Soikkeli-Jalonen et al. 2021;Virdun et al., 2017). However, it has been observed that the healthcare system is designed mainly for the patients, with family members' needs coming second (Røen et al., 2019), and family members often remain unsupported by healthcare professionals, especially with regard to their psychological stress (Salifu et al., 2021).
Supporting family members has not been the main focus of palliative care training (Teixeira et al., 2019), and healthcare professionals do not necessarily have sufficient competence to support family members in a palliative care context; they generally have more knowledge about the physical aspects of the care process (Røen et al., 2019). It can lead to problems in recognising family members' needs and implementing support (Teixeira et al., 2019).
There are few studies on supporting family members in inpatient palliative care (Saarinen et al., 2021;Soikkeli-Jalonen et al., 2021).
The role of families in palliative inpatient care needs further study, as families can easily feel like outsiders in a foreign hospital environment and need support from healthcare professionals to achieve a sense of comfort and ease (Partanen et al., 2018).
Not many studies disclose how support is provided in a palliative care setting from the viewpoint of healthcare professionals or their opportunities for implementing support in daily care, even though their role in providing support for family members is essential (Røen et al., 2019). Even though family members requirements and dissatisfaction about the support during patients' palliative care is stated in studies (Ullrich et al., 2021;Wang et al., 2018), the current research

| AIM
This study aims to describe the healthcare professionals' perceptions of how psychosocial support is provided to family members in palliative inpatient units and how this support can be improved.

| Study design and setting
A qualitative descriptive design was applied. The study was conducted in six specialist palliative care units in five hospitals which are part of two large hospital districts in (Saarto & Finne-Soveri, 2019). Specialist palliative care can be described as holistic care for patients and families, and the healthcare professionals working in specialist units are expected to have expertise (Forbat et al., 2020). In Finland, specialist palliative care is centralised in units whose primary task is arranging palliative care, including end-of-life care. According to official guidelines, the care personnel are recommended to have specific palliative-care training (Saarto & Finne-Soveri, 2019). The consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist was used to ensure detailed and comprehensive reporting during the analysis and reporting process (Tong et al., 2007).

| Participants
Purposive sampling was used to identify informants who had the most appropriate knowledge and understanding of the research subject (Krueger, 2015). Healthcare professionals responsible for planning and performing the daily care of palliative care patients and their families were invited. The inclusion criteria for healthcare professionals were that they must be either physicians, Registered Nurses or practical nurses who were permanently employed in a specialist palliative care inpatient unit. All meeting the inclusion criteria and willing to participate were included, and the number of participants were from eight to 15 from each participating hospital. The data were collected through focus groups of two-to sixperson interviews to provoke a lively debate with various views on the subject represented (Krueger, 2015). Individual interviews were arranged if participation in the focus group could not be arranged, and these interviews were done primarily with doctors, as not many of them work in the same unit. The duration of the interviews ranged between 36 min and 2 h 50 min (Table 1), and the transcribed material contained 248 A4 pages with single-line spacing. In addition, demographic information about participants was collected. The data saturation reached code saturation, and the data were collected until a good viewpoint of all professional groups had been gathered to get a deep view of the categories' content to describe the phenomenon (Hennink et al., 2017). All interviews were recorded via audio.

| Data analysis
Inductive content analysis was used to create a conceptual structure to describe healthcare professionals' perceptions (Elo & Kyngäs, 2008). Inductive content analysis was selected, because the previous research about the topic was limited and there was need to analyse the data to find new insights to the phenomenon.
Furthermore, inductive concept analysis allows data categorisation, which was suitable when processing the unstructured qualitative data (Elo & Kyngäs, 2008).
In the first stage, recorded interviews were transcribed verbatim, and the unit of analysis was selected. In this study, the unit of analysis was a sentence or expression longer than one word that described a healthcare professional's perception. As the aim was to describe healthcare professionals' perceptions, only the manifest data were analysed to ensure the reliability. Second, the entire document was read multiple times to form a general un-  Table 2). All data from different participating professional groups were analysed together as a single dataset.

| Ethics
The study was approved by the Ethics Committee of (REDACTED) (approval number REDACTED). Research permissions were obtained from each hospital accordingly. Ethical standards about the participants' autonomy, privacy, self-determination and anonymity were followed (World Medical Association, 2013). Written informed consent was obtained previously from all participants before the study.
The datasets produced and analysed are not publicly available to protect participants' privacy.

| RE SULTS
Altogether, 48 healthcare professionals participated in the study.
Additional demographic information is presented in Table 1.

| Healthcare professionals' perceptions of psychosocial support
The healthcare professionals' perceptions of psychosocial support for family members produced three main categories: informational support for family members, comprehensive support for family members and methods to improve support for family members. The categorisation is shown in Table 2.

| Informational support to family members
The first main category contained two categories: keeping the family member informed of the care and requirements for information sharing.
Keeping the family member informed of the care included the subcategories of care meetings and general information sharing. Informing family members was implemented by allowing family members to be present at care meetings in which a patient's situation was discussed and planned in a multi-professional group of healthcare professionals and patients.
FGN3: 'We arrange care meetings together with family members, and a doctor, a nurse, relatives, and the patient are present'.
The physician's role in information sharing during the care meetings was emphasised, and new information about a patient's condition or prognosis was seen as the physician's responsibility to share. It was also mentioned that physicians spent considerable time talking with family members.  is to involve the family members in the appointment'.
General information sharing through verbal interaction, providing information leaflets, calling or contacting, and keeping family members informed of updates were described as standard supportive procedures. In addition, participating healthcare professionals shared information with family members about palliative care, symptoms and the disease.   member said that the professionals did not give the support and information they needed and acted against the family.
FGN3: 'We must then respect that the patient does not want information shared with family members'.
FGPN3: 'If the patient says that they do not want anyone to be given information, I have to agree. No matter how angry that family member is, I must respect that patient's right to self-determination'.

| Comprehensive support for family members
The second main category consisted of three subcategories: Supporting family needs, facilitating and mediating family members' and patients' togetherness and supportive encounters.
Supporting family needs describes the support that equips family members to cope and consists of the subcategories taking care of family members' well-being and organising additional support for family members. Taking care of family members' well-being includes, for example, healthcare professionals asking family members whether they are taking care of their physical health, eating, sleeping and taking their medications. In addition, participants report make sure that family members get enough rest and sometimes encourage them to go home for a period of rest and relaxation.
FGN8: 'I often say, "try to take care of yourself, get some rest, go outside for a while", or sometimes just "have you remembered to take your own medicine?"'. In addition, the healthcare professionals take family members' wishes into account. Family members' desire to bring a favourite dish or even pets to the care unit, or to engage in religious or cultural practices, are respected.    Creating confidence that the patient receives good care is a supportive element that participants described as meaningful to family members. Creating an atmosphere of safety and care around the patient gains family members' trust, confidence and perception of being supported. The healthcare professionals in this study perceive that this confidence helps family members release their responsibilities and spend time independently. Confidence and trust in good patient care is understood to enhance family members' coping abilities, allowing them to relax and take breaks from attending to the patient care.
FGPN3: 'And creating a safe, confident feeling for family members so that they could leave here and have trust'. Additionally, healthcare professionals report enabling the presence of family members so that family members can visit the care unit outside of visiting hours; they can stay with the patient overnight and are free to come and go at will. Participants also try to arrange a dedicated space for family members and private rooms for their patients.  Encouraging family members' participation means they are encouraged to come to the care unit, spend time with the patient and participate in the care procedures despite the patient's condition. In addition, healthcare professionals try to promote family members' presence because they know that these could be the last opportunities for family members to spend time with the patient.

Coordinating formal and informal support for family members de-
scribes support activities that should be dedicated to the family members. In general, the healthcare professionals described a need for better consideration of family support, expressing the hope that family members could be taken into account earlier, more often, and more systematically.  The development of bereavement support was another aspect that healthcare professionals perceived as needing improvement. Again, the bereavement support was considered necessary to the family members but has not yet been systematically implemented.   Developing professional competence was described as a necessity.
Participants reported that they would benefit from improved communication skills and the ability to speak straightforwardly and have better encounters with the family members.  The healthcare professionals in this study also said a desire for education on family care. Training was a recurring theme that was suggested as a way to improve the support for family members.
Healthcare providers feel that they are professional in their patient care, but their knowledge of family care needs further development.

| DISCUSS ION
This study presented how psychosocial family support was implemented in hospital palliative care units from the perspective of healthcare professionals involved in the daily care of palliative care patients. The healthcare professionals in this study perceive that the psychosocial support they provide includes informational and comprehensive support for family members, and they also made suggestions about how they experience that support could be improved in their care practices.
Information sharing is recognised as an essential element of support, and the healthcare professionals experience that they carried out communication actively, whether the family members were at the care unit or home. The importance of fair and honest information sharing, communication and the effort to make family members understand the palliative care situation has been observed to promote family support (Anderson et al., 2019;Røen et al., 2019), and the healthcare professional's role implementing informational support is essential to the families as they are the ones whose family members encounter in hospitals, can ask questions and have conversations with about their concerns. However, the healthcare professionals experience as a negative factor that the level of knowledge and information-seeking abilities of family members has developed and increased. Family members' opinions and questions about healthcare professionals' decisions are not without problems, and the need to constantly justify the treatments, medications and patient care to family members is perceived as excessively demanding by the healthcare professionals. Nevertheless, family members are an essential part of patient care, and their need for information and desire to participate is reasonable, and if the healthcare professionals' attitudes towards the family members are negative, there is a risk that it hinders the realisation of information sharing and support (Partanen et al., 2018). It could be beneficial to enhance family-centredness in palliative care environments, so the family members' questions and information seeking would be seen as a positive factor to cooperate for the benefit of the patient's care.
Participants described making many efforts to provide support to promote family members' coping by taking care of their well-being and resilience. Particularly, the importance of practising empathy, having conversations and listening were highlighted. A patient's palliative care situation was seen as a unique event for family members, and participants recognise that they must be treated with particular care. However, the healthcare professionals experienced that the recurrent conversations with family members were demanding and time-consuming, which might indicate the family members' burden and anxiety during palliative inpatient care, emphasising the need for support. In addition, the healthcare professionals described spending considerable resources supporting family members' coping. The healthcare professionals attended to family members various needs and wishes, made efforts to create confidential care relationships and enabled family members' presence and participation as much as possible. However, even though healthcare professionals experience they had make efforts and spend many resources to support the families, the perspective of family members often reveals that their informational or emotional support is not sufficient or that their care needs are not met enough (Røen et al., 2019;Saarinen et al., 2021;Soikkeli-Jalonen et al., 2021;Virdun et al., 2017). According to these results, there must be some discrepancy between the healthcare professional's perception of support provided to families and its perceived benefits compared to family to respond to them.
Furthermore, the importance of family members' own experiences, indicating that although support was given to families, the current support may not always be efficient. More attention should be aimed at recognising family members' need for support and healthcare professionals' opportunities to respond to them.
Furthermore, the importance of family members' participation in patient care was noticed and encouraged by the healthcare professionals. In cancer care settings, family members' closeness to the patient, the care environment, culture and attitudes in the care unit all play vital roles in supporting the family members (Partanen et al., 2018). Healthcare professionals specialising in palliative care saw similar aspects of support as essential. Healthcare professionals said that promoting patient and family togetherness by encouraging the family members' presence and participation is an important supportive element. Furthermore, they perceive that making the environment respective and the atmosphere welcoming makes the family feel supported. In addition, confidential relationships and family members' trust in good patient care are believed to enhance family members' coping abilities. As the importance of acceptance, feeling welcome and promoting family participation are acknowledged by both, the families and healthcare professionals, these important aspects should be better implemented in daily care. At the moment, healthcare environments do not consider families and their needs enough (Røen et al., 2019;Salifu et al., 2021) and family members feel often as outsiders in hospital care (Ullrich et al., 2021).
The healthcare professionals in this study made suggestions for improving practices to support family members, including resources, the need for systematic support and strengthening their competencies in family care. The healthcare professionals said that their organisations had not allocated sufficient resources to the support of families.
Patient care is seen as the priority, and the healthcare professionals do not have enough time to meet and talk with the families, although they want to. However, family members should always be an integral part of palliative care and must be cared for and patients (Steele & Davies, 2015). The need for the comprehensive integration of families still requires more attention when allocating healthcare resources in the palliative care context. The healthcare professionals said a need for better facilities for family members to have their own space in the care unit, the ability to stay overnight and a space to have conversations in private. In general, support focusing exclusively on family members is needed. A systematic support system for family members is perceived to be necessary because currently there is no form of help or guidance for how healthcare providers should assist family members. The healthcare system was constructed to focus on patients, and systematic support options are needed. The findings of this study align with the observation that support opportunities, particularly interventions directed at family members in inpatient palliative care, rarely exist (Saarinen et al., 2021;Soikkeli-Jalonen et al., 2021).
Furthermore, an organised bereavement support system is lacking, even though bereavement support would be helpful to assist family members in coping with the grieving process (Kustanti et al., 2021). In addition, the healthcare professionals in this study express that they would benefit from receiving training in family care in a palliative care setting, and this lack of sufficient training in family care has been observed in a previous study as well (Teixeira et al., 2019).

| Strengths and limitations
Purposive sampling may have influenced the selection of participants, but it facilitated the discovery of eligible informants with experience relevant to the topic. The participants included physicians and nursing staff, so the perspectives of healthcare professionals who do not participate in the regular care of patients and families were not included.
The study participants included more nurses and practical nurses than physicians, which may have given greater emphasis to their perspective. However, nursing staff represent the largest professional group in inpatient units, and the number of participants is proportional to the number of different professions in the units, as generally, there is only one physician per ward. The interviews were carefully planned and constructed such that all the interviews were conducted as similarly as possible. The data collection, performed as a whole without separating perspectives of professions, reached a point of saturation, increasing the credibility of the results. As a descriptive study, the code saturation was perceived as sufficient, and the meaning saturation was not considered necessary (Hennink et al., 2017). However, data saturation about different professional groups is not certain. The data analysis was performed in a research group, with the following consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist was used to ensure detailed and comprehensive reporting during the analysis and reporting processes (Tong et al., 2007). The participants were unable to see the transcripts or results afterwards to add comments, corrections or feedback, because the interviews were conducted in groups and lasted rather long (see Table 1), and in written they comprised long transcripts, so the healthcare professionals time resources would not allow them to delve into them sufficiently.
Additionally, identifying and recognising paragraphs that particular persons had said was very difficult from the written transcripts, and the participants would not get enough information about them.

| CON CLUS IONS
The healthcare professionals describe their perceptions of psychosocial support for family members primarily through patient care and the patient's situation rather than family needs. Direct support for the family members is realised principally by information sharing and conversations, but the other ways of supporting families were not explained much. Healthcare professionals express their opportunities to implement support focusing on family members' needs restricted; organisational resources, such as the time needed to meet the families and appropriate space and environments for family members, were limited in inpatient units. The facilities were not always suitable to support family members' presence and participation. Additionally, there was a need for coordinated and organised support systems for family members that could be implemented in inpatient units by the healthcare professionals as a part of the daily care. Systematic support programmes or models designed for family members and organised bereavement support are needed.
Furthermore, additional training for healthcare professionals in palliative family care is needed.

AUTH O R CO NTR I B UTI O N S
Anu Soikkeli-Jalonen: Conceptualisation, methodology, investigation, data curation, writing (original draft), reviewing, editing, visualisation and funding acquisition. Conceptualisation, methodology, investigation, data curation, writing, reviewing, editing, funding acquisition, supervision and project administration.

ACK N OWLED G EM ENTS
The study was partly funded by The Finnish Association of Nursing Research (2020) and the Finnish Government research funding (Satakunta Hospital District;284/2019, 116/2020.

CO N FLI C T O F I NTE R E S T
The authors declare that there is no conflict of interest.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are partly available upon request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.