Registered nurses’ perceptions of food and mealtimes in palliative care: a cross-sectional study

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Since registered nurses are key caregivers in palliative care, the aim of this study was to explore registered nurses’ perceptions of food and mealtimes in palliative care. Methods An exploratory and descriptive cross-sectional, study-specific survey, designed following a systematic review of the literature, was administered online. The study-specific questionnaire consisted of statements about mealtimes in palliative care, and registered nurses were asked to rate the extent to which they agreed with each statement. Using linear regression analysis associations between socio-demographic variables and registered nurses’ perceptions were explored. Additionally, one open-ended question was analyzed using deductive content analysis. Results Registered nurses (n = 100) had a mean score of 3.3 points on the 4-point scale, indicating that they agreed with the statements about food and mealtimes. Registered nurses agreed to the largest extent with statements concerning r egistered nurses’ responsibilities (mean score 3.7 points), and to the least extent regarding food as improving health and well-being (mean score 2.8 points). Higher age among registered nurses was statistically significant and associated with a lower degree for food and mealtimes are perceived as distressing (P = 0.004) for patients and family. The open-ended question about “what advice would you give a new colleague about food and mealtimes in palliative care?” pertained to the physical (56%), the social (14%), the psychological (9%), and the e xistential dimensions (4%), palliative care approach was covered by 17%) of the text. Conclusions Registered nurses reported that food and mealtimes in palliative care cause distress for patients and families. They strongly agreed on the importance of addressing issues around food and mealtimes at the end of life, helping patients and families to understand that it is common to stop eating as death approaches. Advice to new colleagues often focused on physical care, with fewer registered nurses offering guidance on psychological, social, or existential dimensions. This study highlights the need for support in adopting a holistic approach to palliative care. Experienced clinicians offer crucial perspectives that are vital for specialist palliative care provision. caring eating problems end-of-life families mealtime nursing nutrition palliative care patients perceptions 1. Background Food and mealtimes are essential for physical well-being and symbolize life, providing structure to everyday life ( 1 ). Mealtimes are designated periods during the day when individuals or groups gather to consume food, often serving as opportunities for social interaction, nourishment, and maintaining daily routines. Hence, sharing a meal often involves social gatherings and carries significant connotations ( 2 ). Patients living with chronic life-limiting diseases, i.e. chronic conditions where death is the likely outcome, have described forcing themselves to eat aiming to improve health and to resist death ( 3 ). Difficulties in eating are related to decreased well-being ( 4 ). Aspects of mealtimes, food preparation and intake, have been described as sources of significant distress for patients ( 5 , 6 ) and their families ( 7 , 8 ). Additionally, as food and mealtimes are linked to memories and identity ( 9 ), having eating difficulties fundamentally affect patients’ interactions with friends and family ( 10 , 11 ). Palliative care prioritizes the well-being and quality of life of patients throughout their illness trajectory, emphasizing holistic care, interprofessional collaboration and symptom management ( 12 ). During the course of illness, for patients in palliative care, appetite, willingness to eat, everyday eating patterns and participation in mealtimes might shift significantly from those established prior to the onset of disease, particularly in the final stages of life ( 13 ), confirmed by recent research about the last six months of life or elderly ( 14 ). As the role of food and mealtimes shift, food as a persistent symbol of life may be questioned ( 5 , 11 ), perhaps especially among patients living with chronic life-limiting diseases, and whether they manage to eat or not. To adequately address eating-related distress in palliative care, for patients, as well as family members, future clinical guidelines should consider holistic, multimodal care, including education and psychosocial support ( 6 , 15 ). However, no such guidelines currently exist, resulting in haphazard care related to stressors and eating deficiencies in palliative care ( 16 ). The core of nursing entails promoting health, preventing illness, restoring health, and alleviating suffering ( 17 ), and is well aligned with palliative care ideals of holistic, person-centered care ( 12 ). A recent integrative review outlines core nursing values of specialist palliative nursing as care, compassion and commitment ( 17 ), emphasizing that RNs are uniquely positioned to enhance patient-led care, to be authentically present, and to make a difference. In a hospital setting, core competencies of specialist palliative care nursing were symptom management and discharge planning, though highlighting that the expectations and the role need further clarification ( 18 ). Sweden is considered a country with advanced health system integration of palliative care ( 19 , 20 ) and right to palliative care irrespective of diagnosis is stipulated in national standards and guidelines ( 21 ), though geographic variations and lack of coverage have been found ( 22 ). Palliative care is embedded in both primary and specialized care and patients can often be cared for at home despite level of care, the own home is reported the most preferred place of care and to die ( 23 ). How caring is operationalized in nursing practice and in palliative care influences patients’ and families’ experiences of care ( 24 ). Establishing caring relationships is a core tenet of caring in nursing ( 25 , 26 ), though perceptions about caring differ between patients and RNs. Intended caring is not always perceived as such by patients ( 27 , 28 ), leading to discrepancies in care perceptions. The area of food and mealtimes at the end-of-life has been identified as challenging since difficulties eating disrupt several dimensions, including the social life ( 8 , 29 ). Joy around food and mealtimes diminishes and forced eating to please others and to postpone death is prevalent ( 29 ). Patients and families often report on unmet support needs in relation to nutritional care Hui-Lin ( 30 ). According to the European Society for Clinical Nutrition and Metabolism (ESPEN) the goal of nutritional care and therapy for patients in late phases of end-stage diseases is to improve quality of life ( 31 ). RNs meet patients and families with palliative care needs, often independently as RNs providing palliative care aligned with the nursing process ( 32 ). Both patients and families value individual care, social support, and meaningful activities in hospice ( 33 ). During patients’ illness trajectories, and even close to death, eating difficulties and questions related to food and mealtimes can be of critical importance to patients and families, significantly affecting well-being and daily life, and since RNs work close to the patients and often are responsible for care planning, exploring RNs’ perspectives on these subjects is, therefore, needed. The aim of the present study was to explore RNs’ perceptions of food and mealtimes in palliative care, including their clinical perspectives of patients and families. An additional aim was to investigate associations between RNs’ socio-demographic characteristics and perceptions and mealtimes. 2. Methods Study design and context We designed an exploratory and descriptive cross-sectional survey concerning RNs’ perceptions of food and mealtimes in palliative care as their clinical experience of the topic was relevant for the research aim, more details on the survey will be included further down. The survey was delivered online via advertised links in two Swedish forums for RNs in palliative care. The STROBE reporting guidelines for cross-sectional studies were used to guide structure in research and reporting (34). In Sweden, palliative care is primarily provided outside hospitals, i.e., in primary health care or specialist homecare (35). Palliative care is included within Swedish undergraduate nursing education to some extent but varies a lot between colleges/universities (36, 37). In 2013 a government commission allowed colleges/universities to start specialist training for registered nurses (RNs) on palliative care. According to the Swedish Government’s Official Report (38), 97 RNs had started the program during 2013–2017, but there are no statistical reports of the amount of examined specialist palliative care nurses. Overall, there are approximately 48 000 active RNs in the country. Data collection – survey procedure RNs were recruited by means of convenience sampling, as advertised via a post in a closed group in social media for RNs specialised in palliative care, and in a newsletter within a national association for RNs in palliative care (approximately 80 and 400 members, respectively). The researchers contacted the administrator of the group in social media and the chair of the association, sharing written information about the study and an invitation to distribute the survey. The survey was distributed via an online link and remained live between November and December 2020. Written information about the study and the online link were shared by the administrators of the two groups where participants were invited. In the social media group, two reminders were posted at two-week intervals. The study invitation included in the newsletter from the national association was distributed via email once. Responses were gathered via SurveyMonkey , a web-based tool used to collect data via online surveys. The survey was accessible without a need for a password, and due to the anonymous design, IP addresses were not recorded. The order of the items in the survey was fixed, i.e., items were not changed or randomized depending on participant characteristics. Potential participants were provided written information about the survey by e-mail or via a post in a social media at a group, and a link to the survey. In-depth information was provided on the initial web page when accessing the link to the survey. The text contained information that participation was completely voluntary and anonymous, and that the collected data were to be analysed on group level and published in a scientific journal. Contact information to the principal investigator [ blinded for peer review ] and first author [ blinded for peer review ] was also provided. After the written information, those who wanted to participate were asked to tick a box indicating consent before gaining access to the questions. The two groups from which members i.e., eligible participants were recruited had a combined total of 480 members, of whom 100 chose to participate in the study. Non-response was discussed with the two individuals responsible for disseminating information about the study, resulting in an estimated response rate of approximately 21%. The survey started with questions concerning socio-demographic data and continued with questionnaire items, using 19 statements with fixed answers and one open-ended question. Questions related to socio-demographic data and questionnaire items with fixed answers had to be completed to move on to the next item, whereas the open-ended question could be left blank. All proceedings adhered to ethical principles outlined by the World Medical Association (39), and the study was approved by the Swedish Ethical Review Authority. Socio-demographic variables The following socio-demographic variables were collected: age (year of birth); gender (female/male/not binary/do not want to disclose); number of years since graduation (year of undergraduate RN exam); post-graduate degree in palliative care (Yes/No); other post-graduate degree than palliative care (Yes/No); if “Yes”, i.e., other post-graduate degree, specify which (free text); location of work place (city/suburb/small town/rural); work place (acute care/palliative care or hospice/specialist palliative homecare/primary care/elderly care/other); number of years working as RN ( 10 years); and number of years working in palliative care ( 10 years). Registered nurses’ perceptions of mealtimes in palliative care We constructed a study specific questionnaire based on a recent systematic review, which included 24 articles concerning patients’ perspectives of mealtimes in palliative care [ blinded for peer review ]. We depicted the main findings from the review to explore RNs perceptions of these findings, i.e., 1) Food and mealtimes perceived as distressing, and 2) Affecting social life and interactions, 3) Improving health and well-being as well as 4) Food symbolizing life. Additionally, we included statements about RNs’ perceptions of their responsibilities regarding food and mealtimes in palliative care. These statements, informed by a nursing perspective, are grounded in comprehensive literature searches and reviews within the field of palliative care and nutrition, and are further supported by an empirical study conducted by the first and last authors [ blinded for peer review ]. Content validity, or how well the survey items represent the subject matter (41), was individually reviewed by 13 people: patients in palliative care (n = 2), dieticians (n = 3), physicians (n = 2), and RNs (n = 6). Seven of the clinicians were also active researchers. The written comments were summarized by the first author and subsequently discussed in a workshop with all authors. As a result, two of the statements were clarified and revised (items 16 and 19). The questionnaire was subsequently pilot tested to assess face validity (41), with five RNs working in the context of interest. The questionnaire was found to be clear, relevant, and comprehensible, and thus deemed suitable for the study. Thus, no further revisions were made. A presentation of the statements (n = 19) as well as the order of the statements in the final questionnaire are given in Appendix 1. In the final version of the questionnaire, based on the literature (16), four statements were linked to the domain food and mealtimes perceived as distressing (items 1, 2, 10, and 11), five to affecting social life and interactions (4, 5, 12, 13, and 14), three to improving health and well-being (3, 6, and 7), and four to food symbolizing life (8, 9, 15, and 16). Eleven items are stated from the patients’ perspectives (items 1-11), whereas five are stated from family members’ perspectives (12-16). In addition, three statements concern RNs’ perceptions of their responsibilities regarding food and mealtimes in palliative care: helping patients/family members to accept that it is common to stop eating at the end of life (items 17 and 18) and taking an active part in food and mealtime activities in clinical practice (item 19). The RNs rated each item on a 4-point Likert scale: Strongly disagree (1 point), Disagree (2 points), Agree (3 points), and Strongly agree (4 points). Mean values were calculated for each item, for the five domains ( distressing , affecting social life and interactions , improving health and well-being , food symbolizing life , and RNs’ responsibilities ), as well as for the total 19 items. Open-ended question The RNs were asked an open-ended question: Based on your experience, what advice would you give a new colleague about food and mealtimes in palliative care? The open-ended question was voluntary to answer, and RNs could complete the survey whether they responded to this question or not. There were no limits regarding number of letters or words for responses to this question. Statistical analyses Categorical data are presented as frequencies and percentages, n (%), while ordinal and continuous data are given as means and standard deviations (SDs). For ease of presentation, frequencies and percentages for Yes/No variables are only given for the “Yes” group, since the corresponding values for the “No” group are easily inferred. Unadjusted and adjusted linear regression analysis were used to estimate the magnitude of the associations between all included socio-demographic variables: age (years), female gender (Yes/No), years since nurse exam, post-graduate degree in palliative care (Yes/No), post-graduate degree not in palliative care (Yes/No), working in larger urban area or suburb (Yes/No), working in specialist palliative care service (Yes/No), work experience as RN (0–5 years [reference]/6–10 years/> 10 years) and work experience in palliative care (0–5 years [reference]/6–10 years/> 10 years) (predictors) and RNs’ perceptions of food and mealtimes in palliative care (outcome), separately for the five domains as well as the total group. For all Yes/No variables, “No” was used as reference category. The adjusted analyses included age, female gender and all statistically significant variables from the unadjusted analyses. The results are presented as slope coefficient β with accompanying 95% confidence intervals (CIs). All statistical analyses were performed in R 4.0.0 (R Foundation for Statistical Computing, Vienna, Austria) using two-sided statistical tests with P-values < 0.05 considered statistically significant. No adjustments for multiple comparisons were performed, in line with the arguments provided by Rothman (1990) that such adjustments should be avoided when the analysed data are not random numbers but empirical data from actual observations (42). Analysis of the open-ended question Deductive content analysis (43) was used to categorize responses according to the palliative care dimensions: physical, psychological, social, or existential (44). We created a structured matrix, based on the described competencies related to each dimension in the European Association for Palliative Care (EAPC) position paper, “White Paper on standards and norms for hospice and palliative care in Europe” (45), and relevant data not fitting any of these four dimensions were categorized as other . In the next step, these data were analysed based on principles of manifest inductive content analysis (43), resulting in codes such as person-centred care , relief of suffering , and family caregivers as central . From these codes, an overarching category emerged to capture the overall content. NVivo software (QRS International Pty. Ltd., Australia) was used for this analysis, and it was independently validated by the first and last authors. 3. Results Characteristics of the study sample Most of the 100 participating RNs (94%) were female, they were on average 48.0 (SD 10.0) years old and had completed their nursing degree a mean (SD) 19.0 (SD 10.4) years ago. Four out of five RNs (81%) worked in specialist palliative care units, 41% had post-graduate degrees in palliative care, and 43% had worked > 10 years in palliative care. Characteristics of participating RNs are presented in Table 1. Table 1. Background characteristics of the participants (n=100) Variable Value Age (years), mean (SD) 48.0 (10.0) Female gender, n (%) a 94 (94.0) Male gender, n (%) 4 (6.0) Years since nurse exam, mean (SD) 19.0 (10.4) Post-graduate degree, palliative care, n (%) a 41 (41.0) Post-graduate degree, not palliative care, n (%) a 38 (38.0) Working in larger urban area or suburb, n (%) a 36 (36.0) Working in specialist palliative care division, n (%) a 81 (81.0) Work experience as RN, n (%) – 0–5 years 6 (6.0) – 6–10 years 19 (19.0) – > 10 years 75 (75.0) Work experience in palliative care, n (%) – 0–5 years 28 (28.0) – 6–10 years 29 (29.0) – > 10 years 43 (43.0) Note: RN, registered nurse; SD, standard deviation. There were no missing values for any of the variables. a Yes/No variable. Registered nurses’ perceptions of food and mealtimes in palliative care On average, RNs agreed to the largest extent to the given statements when these concerned RNs’ responsibilities regarding food and mealtimes in palliative care (mean score 3.7 points), while they agreed to the least extent regarding statements concerning Improving health and well-being (mean score 2.8 points). The items with the highest scores were: It is common to stop eating when death is approaching (3.8 points) and RNs should help family members accept that it is common to stop eating at the end of life (3.8 points). The items with the lowest mean scores were: Patients show their will to live by eating (2.7 points) and Patients who manage to eat get vitality and energy to live longer (2.7 points). Table 2 presents RNs ratings (means and SD) on each statement, for each of the five domains, as well as the total score for the 19 statements. Table 2 . RNs’ (n = 100) perceptions of food and mealtimes in palliative care. Item Domains and statements mean SD Food and mealtimes perceived as distressing 1. Many patients experience mealtimes as distressing at the end of life 3.3 0.6 2. Difficulties eating remind patients that death is closing in 3.1 0.6 10. Patients force themselves to eat for the sake of their families 3.2 0.5 11. Conflicts over food and mealtimes between patients and families are common 3.5 0.6 Items 1–2, 10–11 3.3 0.3 Affecting social life and interactions 4. Difficulties eating make patients withdraw from family and friends 2.8 0.6 5. Food and mealtimes entail community and promote relationships 3.5 0.6 12. Family members experience a sense of responsibility for the patient’s eating 3.6 0.6 13. Family members who are women take greater responsibility for the patient’s eating than family members who are men 2.9 0.8 14. Family members organize food and mealtimes because they want to maintain everyday routines 3.1 0.7 Items 4–5, 12–14 3.2 0.4 Improving health and well-being 3. Patients who manage to eat despite deficiencies experience increased well-being 2.9 0.7 6. Patients show their will to live by eating 2.7 0.7 7. Patients who manage to eat gain vitality and the energy to live longer 2.7 0.7 Items 3, 6–7 2.8 0.5 Food symbolizing life 8. For most patients, the illness and bodily changes make it impossible to eat at the end of life 3.4 0.8 9. It is common to stop eating when death is approaching 3.8 0.5 15. Family members focus on food because it is a way to keep death away 3.3 0.6 16. Family members should accept that patients cannot manage to eat 3.3 0.6 Items 8–9, 15–16 3.5 0.4 RNs’ responsibilities 17. RNs should help patients accept that it is common to stop eating at the end of life 3.6 0.5 18. RNs should help family members accept that it is common to stop eating at the end of life 3.8 0.4 19. RNs should take an active part in the work with food and mealtimes at the end of life 3.6 0.6 Items 17–19 3.7 0.4 Total Items 1–19 3.3 0.3 Note: RN, registered nurse; SD, standard deviation. There were no missing values for any of the variables. Associations between socio-demographic variables and registered nurses’ perceptions Results of the linear regression analysis of the associations between age (years), female gender, post-graduate degree, outside palliative care, and work experience as RN (predictors) and RNs’ perceptions of food and mealtimes in palliative care (outcome) are shown in Table 3. Table 3. Results of linear regression analysis of the associations between socio-demographic variables (predictors) and RNs’ perceptions of food and mealtimes in palliative care (outcome). Unadjusted Adjusted a Domain Predictor β (95% CI) P-value β (95% CI) P-value Distressing Age (years) -0.006 (-0.013; 0.001) 0.111 -0.012 (-0.020; -0.004) 0.004 Female gender b 0.287 (-0.0005; 0.575) 0.0504 0.271 (0.002; 0.541) 0.049 Post-graduate degree, not in palliative care b -0.181 (-0.320; -0.042) 0.011 -0.185 (-0.317; -0.053) 0.007 Working experience as RN – 0–5 years Reference – 6–10 years -0.311 (-0.630; 0.007) 0.055 -0.213 (-0.510; 0.083) 0.156 – > 10 years -0.117 (-0.405; 0.172) 0.424 0.137 (-0.157; 0.431) 0.358 Affecting social life and interactions Age (years) -0.002 (-0.010; 0.006) 0.644 -0.008 (-0.018; 0.002) 0.109 Female gender b 0.389 (0.047; 0.732) 0.026 0.342 (-0.001; 0.685) 0.051 Post-graduate degree, not in palliative care b 0.072 (-0.099; 0.243) 0.407 0.072 (-0.096; 0.241) 0.395 Working experience as RN – 0–5 years Reference – 6–10 years -0.475 (-0.852; -0.098) 0.014 -0.392 (-0.770; -0.015) 0.042 – > 10 years -0.236 (-0.578; 0.106) 0.173 -0.110 (-0.484; 0.265) 0.562 Improves health and well-being Age (years) 0.004 (-0.007; 0.014) 0.506 -0.001 (-0.015; 0.012) 0.875 Female gender b 0.058 (-0.394; 0.510) 0.800 -0.027 (-0.493; 0.438) 0.908 Post-graduate degree, not in palliative care b 0.007 (-0.215; 0.228) 0.954 -0.029 (-0.257; 0.200) 0.805 Working experience as RN – 0–5 years Reference – 6–10 years -0.272 (-0.768; 0.224) 0.279 -0.271 (-0.783; 0.242) 0.297 – > 10 years -0.007 (-0.456; 0.442) 0.977 0.018 (-0.491; 0.526) 0.945 Prolongs life Age (years) -0.003 (-0.010; 0.005) 0.489 -0.006 (-0.015; 0.003) 0.224 Female gender b 0.090 (-0.211; 0.392) 0.554 0.102 (-0.210; 0.414) 0.517 Post-graduate degree, not in palliative care b -0.084 (-0.231; 0.063) 0.259 -0.087 (-0.240; 0.066) 0.263 Working experience as RN – 0–5 years Reference – 6–10 years 0.004 (-0.333; 0.342) 0.979 0.047 (-0.296; 0.389) 0.788 – > 10 years 0.057 (-0.249; 0.362) 0.714 0.175 (0.165; 0.516) 0.308 RNs’ responsibilities Age (years) -0.003 (-0.011; 0.004) 0.400 -0.001 (-0.011; 0.009) 0.823 Female gender b 0.025 (-0.294; 0.344) 0.878 0.043 (-0.289; 0.376) 0.797 Post-graduate degree, not in palliative care b -0.038 (-0.194; 0.118) 0.633 -0.017 (-0.181; 0.146) 0.832 Working experience as RN – 0–5 years Reference – 6–10 years -0.096 (-0.451; 0.258) 0.590 -0.085 (-0.450; 0.281) 0.647 – > 10 years -0.167 (-0.487; 0.154) 0.305 -0.142 (-0.505; 0.221) 0.438 Total Age (years) -0.002 (-0.007; 0.003) 0.407 -0.006 (-0.012; 0.00003) 0.051 Female gender b 0.195 (-0.018; 0.408) 0.072 0.171 (-0.041; 0.383) 0.113 Post-graduate degree, not in palliative care b -0.042 (-0.147; 0.064) 0.434 -0.045 (-0.150; 0.059) 0.389 Working experience as RN – 0–5 years Reference – 6–10 years -0.248 (-0.482; -0.014) 0.038 -0.194 (-0.428; 0.039) 0.102 – > 10 years -0.102 (-0.314; 0.110) 0.342 0.017 (-0.214; 0.249) 0.884 Note: CI, confidence interval; RN, registered nurse. None of the variables Years since nursing exam; Post-graduate degree, in palliative care; working in larger urban area or suburb; Working in specialist palliative care division; or Working experience in palliative care were statistically significant in any of the unadjusted analyses. Significant P-values are given in bold. a Adjusted for all other variables in the domain or total. b Yes/No variable, with “No” used as reference category. In the adjusted analyses, female gender was significantly associated with higher agreements on statements that food and mealtimes are perceived as distressing (P = 0.049) and borderline significant (P = 0.051) for food and mealtimes affect social life and interactions (P = 0.026). Higher age was significantly associated with a lower degree of agreement on statements that food and mealtimes are perceived as distressing (P = 0.004). Moreover, having a post-graduate degree in an area other than palliative care was significantly associated with lower agreements on statements that food and mealtimes are perceived as distressing (P = 0.007), while having a 6–10 years’ work experience as RN implied lower agreement on statements that food and mealtimes affect social life and interactions , compared to RNs with 0–5 years work experience (P = 0.042). On average, females had a 0.271 points higher agreement on food and mealtimes are perceived as distressing , and a 0.342 points higher agreement for statements in the domain affect social life and interactions . RNs perceived that food and mealtimes were on average 0.012 points less distressing for each additional year old they were, while RNs with a post-graduate degree in an area other than palliative care had a 0.185 points lower agreement with the statement that food and mealtimes are perceived as distressing . Finally, RNs with a work experience as RN of 6–10 years on average had a 0.392 points lower agreement on statements that food and mealtimes affect social life and interactions , compared with RNs having a shorter work experience of 0–5 years. Registered nurses’ advice to colleagues Most RNs (90%) answered the open-ended question, and the responses collected ranged from two to 330 words (mean 32 words). The total word count from all responses was 3197 words. Responses to the open-ended question regarding advice to a new colleague mostly pertained to physical dimensions of care, followed by psychological, social, and existential dimensions (Table 4). Table 4. RNs’ (n = 90) advice to new colleagues sorted according to WHO’s palliative care dimensions and other dimension, numbers of RNs given answers belonging to each dimension, number of codes, and percentage of text belonging to each dimension. Dimension Number of RNs Number of codes Percentage of text Palliative care dimensions Physical 61 69 56 Social 25 29 14 Psychological 20 21 9 Existential 7 9 4 Other Palliative care approach 10 20 17 The advice regarding the physical dimension , described by 61 RNs, included 69 codes that focused on aspects of eating and how to facilitate and maintain eating throughout the illness trajectory. Examples included practical advice such as adjusting size of meals and food options and eliminating physical reasons for inability to eat (ulcers, mycosis, strictures, etc). The social dimension , described by 25 RNs, included 29 codes that pertained to advising new colleagues about family interventions, e.g., that family members should be given space to eat together with patients. Responses also highlighted RNs’ responsibilities to inform and educate families regarding the dying process and reduced food intake. The most common responses covered individual support to family members and that RNs should help families find strategies to navigate food and eating towards the end-of-life. This could be achieved if families could understand physical deterioration during the dying process and that food no longer is necessary. Advice concerning the psychological dimension , described by 20 RNs, included 21 codes regarding advice to the new colleagues about aspects of enjoyment around food. Several RNs underscored that eating should never be forced and that nagging was negative. Advice regarding the existential dimension , described by seven RNs, included nine codes that focused on life experiences and meanings of eating, like keeping death at bay. A majority (56%) of the responses to the open-ended question pertained advice regarding the physical dimension. In contrast, 14% and 9% of the advice pertained to the social and psychological dimensions , respectively. Existential dimensions were covered by 4%, and palliative care approach in 17% of the text. In the other category, advice from 10 RNs to new colleagues (20 codes) was given concerning strategies for nursing and how to achieve a palliative care approach. The most common advice was to focus on patients’ needs and wishes to form care interventions accordingly, emphasizing that person-centred care , relief of suffering , and family caregivers are central . Using attributes such as humility and respect was also encouraged. To summarize the qualitative data, the physical dimension pertained to practical advice, such as adjusting size of meals and food options, and eliminating physical reasons for inability to eat. The psychological dimension pertained to reactions and emotions such as frustration or sadness. The social dimension pertained to social interactions such as not eating together or not eating the same food and the existential dimension pertained to thoughts of starvation and food as life sustaining. Data not related to these dimensions comprised descriptions concerning the palliative care approach. 4. Discussion This study presents an initial attempt to study RNs’ perceptions about food and mealtimes in relation to specialist palliative care. The RNs in this study agreed that food and mealtimes in palliative care causes psycho-social distress for patients and families. Female gender was significantly associated with higher agreements on statements that food and mealtimes are perceived as distressing and affect social life and interactions , as well as with overall higher agreements on the 19 statements. On the other hand, higher age among RNs was associated with a lower degree of agreement that food and mealtimes are perceived as distressing . Furthermore, RNs strongly agreed that they should actively work with food and mealtimes at the end of life in helping patients and families to accept that it is common to stop eating when death is near . Advice to new colleagues was dominated by physical aspects of care. Fewer RNs suggested advice related to care dimensions with psychological, social, or existential connotations. Support in embracing a palliative care approach was encouraged in general terms. Results in perspective Palliative care philosophy and practice guidelines do emphasize the multidimensional nature of palliative care, comprising physical, psychological, social, and existential needs (12, 44, 45), and a holistic approach to care has been advocated since the early days of the hospice movement (46). Nonetheless, our results show that operationalizing a holistic approach in palliative care nursing seems to present a challenge. The RNs in this study were experienced, well-educated clinicians and may thus represent a normative care culture with regards to food and mealtimes in palliative care. In other words, chances are that new colleagues are socialized into the same norm, potentially focusing on physical aspects of care and consequently neglecting, either consciously or by omission, psychological, social, and existential aspects of care. A recent meta-analysis of RCTs underscores that integrated, holistic palliative care improves patients’ abilities to cope with physical and psychological burdens of cancer, thus leading to overall better well-being (44, 47). A recent meta-synthesis of coping strategies for patients with uncurable illness, confirms that holistic care is crucial (48). There is ample evidence to suggest that education and training programs that emphasize the importance of psychological, social, and existential needs in parallel with physical needs is called for. We suggest that these programs should include practical strategies for integrating these aspects into daily care practices of individual RNs, for example as a fellowship or trainee year with mentoring from (49). We acknowledge that providing integrated, holistic care is challenging in various healthcare settings (50-52). In palliative care, principles of patient-centered and compassionate care are consistently emphasized (17), reiterating that specialist pallative nursing takes patients’ and families’ individual needs, wishes and resourses into account when planning care and during care provision. During the 21st century, we have seen a paradigm shift in palliative care, from focusing on end-of-life care for cancer patients in institutions to broader perspectives including concepts such as life-limiting disease and early intervention (3, 12), health-promoting palliative care (53), and life-enhancing care (54). Thus, the conceptual transitions in palliative care involve moving from terminal diseases and cancer to advanced progressive chronic diseases and limited life expectancy, encompassing all chronic progressive illnesses and conditions. Subsequently, the scope of specialist nursing practice has shifted from symptom management and death is approaching, to well-being and promoting strategies for living with a chronic illness. This shift may not yet have influenced clinical practice regarding food and nutrition in palliative care. Existing guidelines primarily focus on physiological needs (55, 56). Policy changes are needed to directly support holistic care practices. We advocate for the inclusion of comprehensive guidelines on nutritional care in national palliative care standards, ensuring that multiple dimensions of patient well-being are addressed. A review indicates that RNs are aware of the illness trajectory, with dying and death affecting patients, families, and care providers (17). In our results, higher age among RNs was associated with a lower degree of agreement that food and mealtimes are perceived as distressing . Similarly, age was found to affect nursing students’ attitudes towards care of the dying (57). It is unclear whether this is connected to clinical experiences and subsequent personal reflections concerning death and dying or other factors. Benner's (58) novice to expert theory provides a useful framework for understanding the progression of nursing proficiency and its’ impact on holistic nursing practices. Already when patients are admitted to palliative care, RNs know that dying and death are to be expected, even though patients and families may not yet have arrived at the same conclusion (59). RNs are expected to support and inform patients and family, with an imperative to prepare patients and family for a good death. With the diverging understanding and expectations on goals of care between RNs and patients and families, RNs may experience distress since caring for patients and families who are not fully aware of dying is challenging, especially if there are differences or lack of joint goals of care in the healthcare team (60). In the context of palliative care, Benner’s framework (58)) can help explain why experienced RNs might prioritize physical aspects of care. Potentially, RNs in this study focused on physical aspects in relation to food and mealtimes, since there is a multitude of concrete care interventions to try, as suggested by Gillespie and Raftery (61). Their advanced clinical skills allow them to address concrete needs efficiently, while psychological, social, and existential needs may require more nuanced, intuitive approaches that develop over time. In outcomes focused healthcare settings, ‘doing’ nursing interventions that ‘solve’ a physical problem may be preferable to something that takes more time and effort. Research suggests that existential needs may be especially challenging since dying and death is a reality in the near future (62). To be prepared to address existential concerns often involves deep personal reflections on the meaning of life, mortality, and the emotional and spiritual distress associated with the end of life. Nonetheless, provision of specialist palliative care nursing requires engaging with patients and families in creating sensitive, person-centered and individualized support (12). Education and training for individual RNs to operationalize holistic care and developing policy guidelines for nutritional care in palliative care are suggestions to fill the gaps identified by this study. Strengths and limitations Constructing a study-specific questionnaire may present a limitation with regards to internal validity (63). However, statements originated with existing literature and the questionnaire was discussed, tested, and reflected on by a multi-professional group and an expert group for its content and face validity before being used. Steps like these are important when constructing a questionnaire (64, 65). Constructing statements based on research is complex and entails a risk, as they may reflect underlying assumptions made by the researcher. Therefore, testing the statements was essential. Participants responses may also vary depending on their prior assumptions, from experiences or knowledge, and this is not captured here. Another risk is to introduce desirability bias (66) when distributing a questionnaire indicating that there are challenges around food and mealtime. Potentially, RNs may have agreed to participate on those premises, consequently resulting in skewed responses. On the other hand, RNs answered the questions anonymously and could utilize the free text answers for elaboration without any direct influence by researchers. The open-ended question provided RNs with the opportunity to add experiences that were not highlighted in the questionnaire. Given the low response rate (approximately 21%), no claims of generalization can be made. Nonetheless, 100 persons responded during an ongoing pandemic. Recruiting participants via social media and an association for RNs in palliative care mean that reasons for declining participation were unknown. The two groups might have some overlap, as RNs could potentially be members of both groups, and the exact response rate is thus unknown. Sample bias is possible due to the convenience sampling; however, some significant results were found, and the results can potentially generate hypotheses for future research. One possible explanation to having few responders is that no reminders could be sent out to individual persons. Our sample consisted of RNs with extensive clinical experience, and they were highly educated; many had a post-graduate degree in nursing and were experienced in palliative care, thus further limiting the generalization of the findings. However, the sample potentially does indicate how RNs with specialist education view circumstances around food and mealtimes at the end of life. Initial exploration implies that RNs’ perceptions align with patients’ and families’, indicating awareness of the challenges that patients and families face. Another aspect to consider is the gender imbalance with 94% of the participants being women. This is somewhat higher than the proportion of female RNs in Sweden at 87% (67). Despite this gender imbalance, statistically significant gender differences were found, with females to a higher degree agreeing that food and mealtimes are perceived as distressing, and that they affect social life and interactions. Although no conclusions can be drawn regarding the clinical importance of these findings based on our study, the results indicate that exploring these differences further may provide gendered nuances of caring practices. A larger sample focusing on whether gender is associated with perceptions of food and mealtimes, or other core aspects of caring, may yield valuable insights. A larger sample may also have detected potential differences between general and specialised palliative care. 5. Conclusions The RNs in this study reported that food and mealtimes in palliative care cause distress for patients and families They strongly agreed on the importance of actively addressing issues around food and mealtimes at the end of life, helping patients and families to understand that it is common to stop eating as death approaches. Advice to new colleagues primarily focused on physical aspects of care; with fewer RNs offering guidance on psychological, social, or existential dimensions. These needs may be seen as more challenging to address because they are not as easily remedied. Support in embracing a palliative care approach was encouraged in general terms, aligning with professional competence and development. This study suggests that experienced clinicians offer crucial perspectives for specialist palliative care provision. Declarations Acknowledgements We would like to thank the 100 RNs who took their time and participated. We would also like to thank the researchers, RNs and patients who evaluated the questionnaire for giving critical input when constructing the questionnaire. Authors’ contributions The first, second, and last authors contributed to the conception and design. All authors contributed to creating the survey statements. The third author facilitated the data collection. All authors contributed to the analysis and interpretation of the data. All authors contributed to the drafting and critical revision of the manuscript. Availability of data and materials The questionnaire statements are included in the article. The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Consent for publication Not applicable. Funding No funding was obtained. 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Statistics about registered healthcare professionals 2023 and occupation 2022. Statistik om legitimerad hälso- och sjukvårdspersonal 2023 samt arbetsmarknadsstatus 2022. Stockholm Swed, 2023. Additional Declarations No competing interests reported. Supplementary Files Appendix1.docx Cite Share Download PDF Status: Published Journal Publication published 29 Nov, 2025 Read the published version in BMC Palliative Care → Version 1 posted Editorial decision: Revision requested 09 May, 2025 Reviewers invited by journal 28 Apr, 2025 Submission checks completed at journal 24 Apr, 2025 First submitted to journal 23 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6128968","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":449694521,"identity":"28bd72a4-b68a-430b-afc6-c837b1574e68","order_by":0,"name":"Viktoria Wallin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+UlEQVRIie3OvWrDMBDA8RMBZRFkvWKIX0HBYDL041VkDPaSlDxBUQi4Y9f0ITp08dRBQVAv7p6hg6dMHdTd0FohUDooWjPoPxzc8OMOIBS6xEbUTrSDqI7DFIB5CZEnAkpwSPwEjgROBCCTPsIbWnbfb/MYMO+UWH2WL48f2kB/7Saa7tbbA84kFnx47LCs2/sCSVU4ydVmvN4whURGwhK9rPcsBSK1l9zJqDSWlOmeJcNjP04yGdGdJZmMFscrYiAcgapzJHveKsyr+GtlyaxuFylmVe4kdPLOjVEPN0+see1Mr+O0aRNj+lsn+bP/NuEHoVAoFDrTL5DyVvFoLh7SAAAAAElFTkSuQmCC","orcid":"","institution":"Marie Cederschiöld University","correspondingAuthor":true,"prefix":"","firstName":"Viktoria","middleName":"","lastName":"Wallin","suffix":""},{"id":449694522,"identity":"1fa61f60-74ca-46ea-8935-fa512fdaf4aa","order_by":1,"name":"Andreas Rosenblad","email":"","orcid":"","institution":"Uppsala University","correspondingAuthor":false,"prefix":"","firstName":"Andreas","middleName":"","lastName":"Rosenblad","suffix":""},{"id":449694523,"identity":"08c8dead-9a43-4876-82f3-a6180ede63af","order_by":2,"name":"Carina Lundh Hagelin","email":"","orcid":"","institution":"Marie Cederschiöld University","correspondingAuthor":false,"prefix":"","firstName":"Carina","middleName":"Lundh","lastName":"Hagelin","suffix":""},{"id":449694524,"identity":"849e162b-0a5f-4a7d-908a-f597831b3df4","order_by":3,"name":"Anna Klarare","email":"","orcid":"","institution":"Boston College","correspondingAuthor":false,"prefix":"","firstName":"Anna","middleName":"","lastName":"Klarare","suffix":""}],"badges":[],"createdAt":"2025-02-28 13:23:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6128968/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6128968/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12904-025-01935-8","type":"published","date":"2025-11-29T15:58:51+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":97178698,"identity":"1d3f4c0c-86b8-444b-be29-8d2998c55685","added_by":"auto","created_at":"2025-12-01 16:12:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1213426,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6128968/v1/3ea706b0-557b-46e3-bfa5-4858fec99b88.pdf"},{"id":81679129,"identity":"88811252-daca-4d47-a812-514fa33e516c","added_by":"auto","created_at":"2025-04-30 08:36:53","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":15697,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6128968/v1/fe9d04fd4323f532f106cee2.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Registered nurses’ perceptions of food and mealtimes in palliative care: a cross-sectional study","fulltext":[{"header":"1. Background","content":"\u003cp\u003eFood and mealtimes are essential for physical well-being and symbolize life, providing structure to everyday life (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Mealtimes are designated periods during the day when individuals or groups gather to consume food, often serving as opportunities for social interaction, nourishment, and maintaining daily routines. Hence, sharing a meal often involves social gatherings and carries significant connotations (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Patients living with chronic life-limiting diseases, i.e. chronic conditions where death is the likely outcome, have described forcing themselves to eat aiming to improve health and to resist death (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Difficulties in eating are related to decreased well-being (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Aspects of mealtimes, food preparation and intake, have been described as sources of significant distress for patients (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) and their families (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Additionally, as food and mealtimes are linked to memories and identity (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), having eating difficulties fundamentally affect patients\u0026rsquo; interactions with friends and family (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003ePalliative care prioritizes the well-being and quality of life of patients throughout their illness trajectory, emphasizing holistic care, interprofessional collaboration and symptom management (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). During the course of illness, for patients in palliative care, appetite, willingness to eat, everyday eating patterns and participation in mealtimes might shift significantly from those established prior to the onset of disease, particularly in the final stages of life (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), confirmed by recent research about the last six months of life or elderly (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAs the role of food and mealtimes shift, food as a persistent symbol of life may be questioned (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), perhaps especially among patients living with chronic life-limiting diseases, and whether they manage to eat or not. To adequately address eating-related distress in palliative care, for patients, as well as family members, future clinical guidelines should consider holistic, multimodal care, including education and psychosocial support (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). However, no such guidelines currently exist, resulting in haphazard care related to stressors and eating deficiencies in palliative care (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe core of nursing entails promoting health, preventing illness, restoring health, and alleviating suffering (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), and is well aligned with palliative care ideals of holistic, person-centered care (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). A recent integrative review outlines core nursing values of specialist palliative nursing as care, compassion and commitment (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), emphasizing that RNs are uniquely positioned to enhance patient-led care, to be authentically present, and to make a difference. In a hospital setting, core competencies of specialist palliative care nursing were symptom management and discharge planning, though highlighting that the expectations and the role need further clarification (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Sweden is considered a country with advanced health system integration of palliative care (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) and right to palliative care irrespective of diagnosis is stipulated in national standards and guidelines (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), though geographic variations and lack of coverage have been found (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Palliative care is embedded in both primary and specialized care and patients can often be cared for at home despite level of care, the own home is reported the most preferred place of care and to die (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). How caring is operationalized in nursing practice and in palliative care influences patients\u0026rsquo; and families\u0026rsquo; experiences of care (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Establishing caring relationships is a core tenet of caring in nursing (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), though perceptions about caring differ between patients and RNs. Intended caring is not always perceived as such by patients (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), leading to discrepancies in care perceptions.\u003c/p\u003e\u003cp\u003eThe area of food and mealtimes at the end-of-life has been identified as challenging since difficulties eating disrupt several dimensions, including the social life (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Joy around food and mealtimes diminishes and forced eating to please others and to postpone death is prevalent (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Patients and families often report on unmet support needs in relation to nutritional care Hui-Lin (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). According to the European Society for Clinical Nutrition and Metabolism (ESPEN) the goal of nutritional care and therapy for patients in late phases of end-stage diseases is to improve quality of life (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). RNs meet patients and families with palliative care needs, often independently as RNs providing palliative care aligned with the nursing process (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Both patients and families value individual care, social support, and meaningful activities in hospice (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). During patients\u0026rsquo; illness trajectories, and even close to death, eating difficulties and questions related to food and mealtimes can be of critical importance to patients and families, significantly affecting well-being and daily life, and since RNs work close to the patients and often are responsible for care planning, exploring RNs\u0026rsquo; perspectives on these subjects is, therefore, needed. The aim of the present study was to explore RNs\u0026rsquo; perceptions of food and mealtimes in palliative care, including their clinical perspectives of patients and families. An additional aim was to investigate associations between RNs\u0026rsquo; socio-demographic characteristics and perceptions and mealtimes.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"2. Methods","content":"\u003ch3\u003e\u003cstrong\u003eStudy design and context\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eWe designed an exploratory and descriptive cross-sectional survey concerning RNs\u0026rsquo; perceptions of food and mealtimes in palliative care as their clinical experience of the topic was relevant for the research aim, more details on the survey will be included further down.\u0026nbsp;The survey was delivered online via advertised links in two Swedish forums for RNs in palliative care. The STROBE reporting guidelines for cross-sectional studies were used to guide structure in research and reporting (34).\u003c/p\u003e\n\u003cp\u003eIn Sweden, palliative care is primarily provided outside hospitals, i.e., in primary health care or specialist homecare (35). Palliative care is included within Swedish undergraduate nursing education to some extent but varies a lot between colleges/universities (36, 37). In 2013 a government commission allowed colleges/universities to start specialist training for registered nurses (RNs) on palliative care. According to the Swedish Government\u0026rsquo;s Official Report (38), 97 RNs had started the program during 2013\u0026ndash;2017, but there are no statistical reports of the amount of examined specialist palliative care nurses. Overall, there are approximately 48\u0026nbsp;000 active RNs in the country.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eData collection \u0026ndash; survey procedure\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eRNs were recruited by means of convenience sampling, as advertised via a post in a closed group in social media for RNs specialised in palliative care, and in a newsletter within a national association for RNs in palliative care (approximately 80 and 400 members, respectively). The researchers contacted the administrator of the group in social media and the chair of the association, sharing written information about the study and an invitation to distribute the survey. The survey was distributed via an online link and remained live between November and December 2020. Written information about the study and the online link were shared by the administrators of the two groups where participants were invited. In the social media group, two reminders were posted at two-week intervals. The study invitation included in the newsletter from the national association was distributed via email once. Responses were gathered via \u003cem\u003eSurveyMonkey\u003c/em\u003e, a web-based tool used to collect data via online surveys. The survey was accessible without a need for a password, and due to the anonymous design, IP addresses were not recorded. The order of the items in the survey was fixed, i.e., items were not changed or randomized depending on participant characteristics.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePotential participants were provided written information about the survey by e-mail or via a post in a social media at a group, and a link to the survey. In-depth information was provided on the initial web page when accessing the link to the survey. The text contained information that participation was completely voluntary and anonymous, and that the collected data were to be analysed on group level and published in a scientific journal. Contact information to the principal investigator [\u003cem\u003eblinded for peer review\u003c/em\u003e] and first author [\u003cem\u003eblinded for peer review\u003c/em\u003e] was also provided. After the written information, those who wanted to participate were asked to tick a box indicating consent before gaining access to the questions.\u0026nbsp;\u003c/p\u003e\n\u003cp skip=\"true\"\u003eThe two groups from which members i.e., eligible participants were recruited had a combined total of 480 members, of whom 100 chose to participate in the study. Non-response was discussed with the two individuals responsible for disseminating information about the study, resulting in an estimated response rate of approximately 21%. The survey started with questions concerning socio-demographic data and continued with questionnaire items, using 19 statements with fixed answers and one open-ended question. Questions related to socio-demographic data and questionnaire items with fixed answers had to be completed to move on to the next item, whereas the open-ended question could be left blank. All proceedings adhered to ethical principles outlined by the World Medical Association (39), and the study was approved by the Swedish Ethical Review Authority.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eSocio-demographic variables\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe following socio-demographic variables were collected: age (year of birth); gender (female/male/not binary/do not want to disclose); number of years since graduation (year of undergraduate RN exam); post-graduate degree in palliative care (Yes/No); other post-graduate degree than palliative care (Yes/No); if \u0026ldquo;Yes\u0026rdquo;, i.e., other post-graduate degree, specify which (free text); location of work place (city/suburb/small town/rural); work place (acute care/palliative care or hospice/specialist palliative homecare/primary care/elderly care/other); number of years working as RN (\u0026lt; 1/1\u0026ndash;5/6\u0026ndash;10/\u0026gt; 10 years); and number of years working in palliative care (\u0026lt; 1/1\u0026ndash;5/6\u0026ndash;10/\u0026gt; 10 years).\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eRegistered nurses\u0026rsquo; perceptions of mealtimes in palliative care\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eWe constructed a study specific questionnaire based on a recent systematic review, which included 24 articles concerning patients\u0026rsquo; perspectives of mealtimes in palliative care [\u003cem\u003eblinded for peer review\u003c/em\u003e]. We depicted the main findings from the review to explore RNs perceptions of these findings, i.e., 1) Food and mealtimes perceived as distressing, and 2) Affecting social life and interactions, 3) Improving health and well-being as well as 4) Food symbolizing life. Additionally, we included statements about RNs\u0026rsquo; perceptions of their responsibilities regarding food and mealtimes in palliative care. These statements, informed by a nursing perspective, are grounded in comprehensive literature searches and reviews within the field of palliative care and nutrition, and are further supported by an empirical study conducted by the first and last authors [\u003cem\u003eblinded for peer review\u003c/em\u003e].\u003c/p\u003e\n\u003cp\u003eContent validity, or how well the survey items represent the subject matter (41), was individually reviewed by 13 people: patients in palliative care (n = 2), dieticians (n = 3), physicians (n = 2), and RNs (n = 6). Seven of the clinicians were also active researchers. The written comments were summarized by the first author and subsequently discussed in a workshop with all authors. As a result, two of the statements were clarified and revised (items 16 and 19). The questionnaire was subsequently pilot tested to assess face validity (41), with five RNs working in the context of interest. The questionnaire was found to be clear, relevant, and comprehensible, and thus deemed suitable for the study. Thus, no further revisions were made. A presentation of the statements (n = 19) as well as the order of the statements in the final questionnaire are given in Appendix 1.\u003c/p\u003e\n\u003cp\u003eIn the final version of the questionnaire, based on the literature (16), four statements were linked to the domain \u003cem\u003efood and mealtimes perceived as distressing\u003c/em\u003e (items 1, 2, 10, and 11), five to\u003cem\u003e\u0026nbsp;affecting social life and interactions\u003c/em\u003e (4, 5, 12, 13, and 14), three to \u003cem\u003eimproving health and well-being\u003c/em\u003e (3, 6, and 7), and four to \u003cem\u003efood symbolizing life\u003c/em\u003e (8, 9, 15, and 16). Eleven items are stated from the patients\u0026rsquo; perspectives (items 1-11), whereas five are stated from family members\u0026rsquo; perspectives (12-16). In addition, three statements concern RNs\u0026rsquo; perceptions of their responsibilities regarding food and mealtimes in palliative care: \u003cem\u003ehelping patients/family members to accept that it is common to stop eating at the end of life\u003c/em\u003e (items 17 and 18) and \u003cem\u003etaking an active part in food and mealtime activities in clinical practice\u003c/em\u003e (item 19).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe RNs rated each item on a 4-point Likert scale: \u003cem\u003eStrongly disagree\u003c/em\u003e (1 point), \u003cem\u003eDisagree\u003c/em\u003e (2 points), \u003cem\u003eAgree\u003c/em\u003e (3 points), and \u003cem\u003eStrongly agree\u003c/em\u003e (4 points). Mean values were calculated for each item, for the five domains (\u003cem\u003edistressing\u003c/em\u003e, \u003cem\u003eaffecting social life and interactions\u003c/em\u003e, \u003cem\u003eimproving health and well-being\u003c/em\u003e, \u003cem\u003efood symbolizing life\u003c/em\u003e, and \u003cem\u003eRNs\u0026rsquo; responsibilities\u003c/em\u003e), as well as for the total 19 items.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eOpen-ended question\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe RNs were asked an open-ended question: \u003cem\u003eBased on your experience, what advice would you give a new colleague about food and mealtimes in palliative care?\u003c/em\u003e The open-ended question was voluntary to answer, and RNs could complete the survey whether they responded to this question or not. There were no limits regarding number of letters or words for responses to this question.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eStatistical analyses\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eCategorical data are presented as frequencies and percentages, n (%), while ordinal and continuous data are given as means and standard deviations (SDs). For ease of presentation, frequencies and percentages for Yes/No variables are only given for the \u0026ldquo;Yes\u0026rdquo; group, since the corresponding values for the \u0026ldquo;No\u0026rdquo; group are easily inferred. Unadjusted and adjusted linear regression analysis were used to estimate the magnitude of the associations between all included socio-demographic variables: age (years), female gender (Yes/No), years since nurse exam, post-graduate degree in palliative care (Yes/No), post-graduate degree not in palliative care (Yes/No), working in larger urban area or suburb (Yes/No), working in specialist palliative care service (Yes/No), work experience as RN (0\u0026ndash;5 years [reference]/6\u0026ndash;10 years/\u0026gt; 10 years) and work experience in palliative care (0\u0026ndash;5 years [reference]/6\u0026ndash;10 years/\u0026gt; 10 years) (predictors) and RNs\u0026rsquo; perceptions of food and mealtimes in palliative care (outcome), separately for the five domains as well as the total group. For all Yes/No variables, \u0026ldquo;No\u0026rdquo; was used as reference category.\u003c/p\u003e\n\u003cp\u003eThe adjusted analyses included age, female gender and all statistically significant variables from the unadjusted analyses. The results are presented as slope coefficient \u0026beta; with accompanying 95% confidence intervals (CIs). All statistical analyses were performed in R 4.0.0 (R Foundation for Statistical Computing, Vienna, Austria) using two-sided statistical tests with P-values \u0026lt; 0.05 considered statistically significant. No adjustments for multiple comparisons were performed, in line with the arguments provided by Rothman (1990) that such adjustments should be avoided when the analysed data are not random numbers but empirical data from actual observations (42).\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eAnalysis of the open-ended question\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eDeductive content analysis (43) was used to categorize responses according to the palliative care dimensions: \u003cem\u003ephysical, psychological, social,\u003c/em\u003e or \u003cem\u003eexistential\u003c/em\u003e (44). We created a structured matrix, based on the described competencies related to each dimension in the European Association for Palliative Care (EAPC) position paper, \u0026ldquo;White Paper on standards and norms for hospice and palliative care in Europe\u0026rdquo; (45), and relevant data not fitting any of these four dimensions were categorized as \u003cem\u003eother\u003c/em\u003e. In the next step, these data were analysed based on principles of manifest inductive content analysis (43), resulting in codes such as \u003cem\u003eperson-centred care\u003c/em\u003e, \u003cem\u003erelief of suffering\u003c/em\u003e, and \u003cem\u003efamily caregivers as central\u003c/em\u003e. From these codes, an overarching category emerged to capture the overall content. NVivo software (QRS International Pty. Ltd., Australia) was used for this analysis, and it was independently validated by the first and last authors.\u003c/p\u003e"},{"header":"3. Results","content":"\u003ch3\u003e\u003cstrong\u003eCharacteristics of the study sample\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eMost of the 100 participating RNs (94%) were female, they were on average 48.0 (SD 10.0) years old and had completed their nursing degree a mean (SD) 19.0 (SD 10.4) years ago. Four out of five RNs (81%) worked in specialist palliative care units, 41% had post-graduate degrees in palliative care, and 43% had worked \u0026gt; 10 years in palliative care. Characteristics of participating RNs are presented in Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Background characteristics of the participants (n=100)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 501px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eValue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 501px;\"\u003e\n \u003cp\u003eAge (years), mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e48.0 (10.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 501px;\"\u003e\n \u003cp\u003eFemale gender, n (%)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e94 (94.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 501px;\"\u003e\n \u003cp\u003eMale gender, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e4 (6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 501px;\"\u003e\n \u003cp\u003eYears since nurse exam, mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e19.0 (10.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 501px;\"\u003e\n \u003cp\u003ePost-graduate degree, palliative care, n (%)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e41 (41.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 501px;\"\u003e\n \u003cp\u003ePost-graduate degree, not palliative care, n (%)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e38 (38.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 501px;\"\u003e\n \u003cp\u003eWorking in larger urban area or suburb, n (%)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e36 (36.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 501px;\"\u003e\n \u003cp\u003eWorking in specialist palliative care division, n (%)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e81 (81.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 501px;\"\u003e\n \u003cp\u003eWork experience as RN, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 501px;\"\u003e\n \u003cp\u003e\u0026ndash; 0\u0026ndash;5 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e6 (6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 501px;\"\u003e\n \u003cp\u003e\u0026ndash; 6\u0026ndash;10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e19 (19.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 501px;\"\u003e\n \u003cp\u003e\u0026ndash; \u0026gt; 10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e75 (75.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 501px;\"\u003e\n \u003cp\u003eWork experience in palliative care, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 501px;\"\u003e\n \u003cp\u003e\u0026ndash; 0\u0026ndash;5 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e28 (28.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 501px;\"\u003e\n \u003cp\u003e\u0026ndash; 6\u0026ndash;10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e29 (29.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 501px;\"\u003e\n \u003cp\u003e\u0026ndash; \u0026gt; 10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e43 (43.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: RN, registered nurse; SD, standard deviation. There were no missing values for any of the variables. \u003csup\u003ea\u003c/sup\u003e Yes/No variable.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/h3\u003e\n\u003ch3\u003e\u003cstrong\u003eRegistered nurses\u0026rsquo; perceptions of food and mealtimes in palliative care\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eOn average, RNs agreed to the largest extent to the given statements when these concerned \u003cem\u003eRNs\u0026rsquo; responsibilities regarding food and mealtimes in palliative care\u0026nbsp;\u003c/em\u003e(mean score 3.7 points), while they agreed to the least extent regarding statements concerning \u003cem\u003eImproving health and well-being\u003c/em\u003e (mean score 2.8 points). The items with the highest scores were: \u003cem\u003eIt is common to stop eating when death is approaching\u003c/em\u003e (3.8 points) and \u003cem\u003eRNs should help family members accept that it is common to stop eating at the end of life\u003c/em\u003e (3.8 points). The items with the lowest mean scores were: \u003cem\u003ePatients show their will to live by eating\u003c/em\u003e (2.7 points) and \u003cem\u003ePatients who manage to eat get vitality and energy to live longer\u003c/em\u003e (2.7 points). Table 2 presents RNs ratings (means and SD) on each statement, for each of the five domains, as well as the total score for the 19 statements.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e. RNs\u0026rsquo; (n = 100) perceptions of food and mealtimes in palliative care.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"548\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eItem\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 410px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDomains and statements\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003emean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 410px;\"\u003e\n \u003cp\u003e\u003cem\u003eFood and mealtimes perceived as distressing\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e1.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 410px;\"\u003e\n \u003cp\u003eMany patients experience mealtimes as distressing at the end of life\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e2.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 410px;\"\u003e\n \u003cp\u003eDifficulties eating remind patients that death is closing in\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e3.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e10.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 410px;\"\u003e\n \u003cp\u003ePatients force themselves to eat for the sake of their families\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e11.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 410px;\"\u003e\n \u003cp\u003eConflicts over food and mealtimes between patients and families are common\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 410px;\"\u003e\n \u003cp\u003eItems 1\u0026ndash;2, 10\u0026ndash;11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 410px;\"\u003e\n \u003cp\u003e\u003cem\u003eAffecting social life and interactions\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e4.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 410px;\"\u003e\n \u003cp\u003eDifficulties eating make patients withdraw from family and friends\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e5.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 410px;\"\u003e\n \u003cp\u003eFood and mealtimes entail community and promote relationships\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e12.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 410px;\"\u003e\n \u003cp\u003eFamily members experience a sense of responsibility for the patient\u0026rsquo;s eating\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e13.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 410px;\"\u003e\n \u003cp\u003eFamily members who are women take greater responsibility for the patient\u0026rsquo;s eating than family members who are men\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e14.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 410px;\"\u003e\n \u003cp\u003eFamily members organize food and mealtimes because they want to maintain everyday routines\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e3.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 410px;\"\u003e\n \u003cp\u003eItems 4\u0026ndash;5, 12\u0026ndash;14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 410px;\"\u003e\n \u003cp\u003e\u003cem\u003eImproving health and well-being\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e3.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 410px;\"\u003e\n \u003cp\u003ePatients who manage to eat despite deficiencies experience increased well-being\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e6.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 410px;\"\u003e\n \u003cp\u003ePatients show their will to live by eating\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e7.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 410px;\"\u003e\n \u003cp\u003ePatients who manage to eat gain vitality and the energy to live longer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 410px;\"\u003e\n \u003cp\u003eItems 3, 6\u0026ndash;7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 410px;\"\u003e\n \u003cp\u003e\u003cem\u003eFood symbolizing life\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e8.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 410px;\"\u003e\n \u003cp\u003eFor most patients, the illness and bodily changes make it impossible to eat at the end of life\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e9.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 410px;\"\u003e\n \u003cp\u003eIt is common to stop eating when death is approaching\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e15.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 410px;\"\u003e\n \u003cp\u003eFamily members focus on food because it is a way to keep death away\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e16.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 410px;\"\u003e\n \u003cp\u003eFamily members should accept that patients cannot manage to eat\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 410px;\"\u003e\n \u003cp\u003eItems 8\u0026ndash;9, 15\u0026ndash;16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 410px;\"\u003e\n \u003cp\u003e\u003cem\u003eRNs\u0026rsquo; responsibilities\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e17.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 410px;\"\u003e\n \u003cp\u003eRNs should help patients accept that it is common to stop eating at the end of life\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e18.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 410px;\"\u003e\n \u003cp\u003eRNs should help family members accept that it is common to stop eating at the end of life\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e19.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 410px;\"\u003e\n \u003cp\u003eRNs should take an active part in the work with food and mealtimes at the end of life\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 410px;\"\u003e\n \u003cp\u003eItems 17\u0026ndash;19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 410px;\"\u003e\n \u003cp\u003e\u003cem\u003eTotal\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 410px;\"\u003e\n \u003cp\u003eItems 1\u0026ndash;19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: RN, registered nurse; SD, standard deviation. There were no missing values for any of the variables.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eAssociations between socio-demographic variables and registered nurses\u0026rsquo; perceptions\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eResults of the linear regression analysis of the associations between age (years), female gender, post-graduate degree, outside palliative care, and work experience as RN (predictors) and RNs\u0026rsquo; perceptions of food and mealtimes in palliative care (outcome) are shown in Table 3.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u003c/strong\u003e Results of linear regression analysis of the associations between socio-demographic variables (predictors) and RNs\u0026rsquo; perceptions of food and mealtimes in palliative care (outcome).\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"621\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnadjusted\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 167px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdjusted\u003c/strong\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDomain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePredictor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026beta; (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026beta; (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eDistressing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.006 (-0.013; 0.001)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.111\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e-0.012 (-0.020; -0.004)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.004\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eFemale gender\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.287 (-0.0005; 0.575)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.0504\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.271 (0.002; 0.541)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.049\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003ePost-graduate degree, not in palliative care\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.181 (-0.320; -0.042)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.011\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e-0.185 (-0.317; -0.053)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.007\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eWorking experience as RN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026ndash; 0\u0026ndash;5 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026ndash; 6\u0026ndash;10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.311 (-0.630; 0.007)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.055\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e-0.213 (-0.510; 0.083)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0.156\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026ndash; \u0026gt; 10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.117 (-0.405; 0.172)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.424\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.137 (-0.157; 0.431)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0.358\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eAffecting social life and interactions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.002 (-0.010; 0.006)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.644\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e-0.008 (-0.018; 0.002)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0.109\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eFemale gender\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.389 (0.047; 0.732)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.026\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.342 (-0.001; 0.685)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0.051\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003ePost-graduate degree, not in palliative care\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.072 (-0.099; 0.243)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.407\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.072 (-0.096; 0.241)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0.395\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eWorking experience as RN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026ndash; 0\u0026ndash;5 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026ndash; 6\u0026ndash;10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.475 (-0.852; -0.098)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.014\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e-0.392 (-0.770; -0.015)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.042\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026ndash; \u0026gt; 10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.236 (-0.578; 0.106)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.173\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e-0.110 (-0.484; 0.265)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0.562\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eImproves health and well-being\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.004 (-0.007; 0.014)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.506\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e-0.001 (-0.015; 0.012)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0.875\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eFemale gender\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.058 (-0.394; 0.510)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.800\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e-0.027 (-0.493; 0.438)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0.908\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003ePost-graduate degree, not in palliative care\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.007 (-0.215; 0.228)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.954\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e-0.029 (-0.257; 0.200)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0.805\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eWorking experience as RN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026ndash; 0\u0026ndash;5 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026ndash; 6\u0026ndash;10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.272 (-0.768; 0.224)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.279\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e-0.271 (-0.783; 0.242)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0.297\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026ndash; \u0026gt; 10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.007 (-0.456; 0.442)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.977\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.018 (-0.491; 0.526)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0.945\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eProlongs life\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.003 (-0.010; 0.005)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.489\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e-0.006 (-0.015; 0.003)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0.224\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eFemale gender\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.090 (-0.211; 0.392)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.554\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.102 (-0.210; 0.414)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0.517\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003ePost-graduate degree, not in palliative care\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.084 (-0.231; 0.063)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.259\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e-0.087 (-0.240; 0.066)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0.263\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eWorking experience as RN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026ndash; 0\u0026ndash;5 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026ndash; 6\u0026ndash;10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.004 (-0.333; 0.342)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.979\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.047 (-0.296; 0.389)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0.788\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026ndash; \u0026gt; 10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.057 (-0.249; 0.362)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.714\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.175 (0.165; 0.516)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0.308\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eRNs\u0026rsquo; responsibilities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.003 (-0.011; 0.004)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.400\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e-0.001 (-0.011; 0.009)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0.823\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eFemale gender\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.025 (-0.294; 0.344)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.878\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.043 (-0.289; 0.376)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0.797\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003ePost-graduate degree, not in palliative care\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.038 (-0.194; 0.118)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.633\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e-0.017 (-0.181; 0.146)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0.832\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eWorking experience as RN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026ndash; 0\u0026ndash;5 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026ndash; 6\u0026ndash;10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.096 (-0.451; 0.258)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.590\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e-0.085 (-0.450; 0.281)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0.647\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026ndash; \u0026gt; 10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.167 (-0.487; 0.154)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.305\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e-0.142 (-0.505; 0.221)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0.438\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.002 (-0.007; 0.003)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.407\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e-0.006 (-0.012; 0.00003)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0.051\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eFemale gender\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.195 (-0.018; 0.408)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.072\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.171 (-0.041; 0.383)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0.113\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003ePost-graduate degree, not in palliative care\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.042 (-0.147; 0.064)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.434\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e-0.045 (-0.150; 0.059)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0.389\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eWorking experience as RN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026ndash; 0\u0026ndash;5 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026ndash; 6\u0026ndash;10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.248 (-0.482; -0.014)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.038\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e-0.194 (-0.428; 0.039)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0.102\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026ndash; \u0026gt; 10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e-0.102 (-0.314; 0.110)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.342\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.017 (-0.214; 0.249)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0.884\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: CI, confidence interval; RN, registered nurse. None of the variables Years since nursing exam; Post-graduate degree, in palliative care; working in larger urban area or suburb; Working in specialist palliative care division; or Working experience in palliative care were statistically significant in any of the unadjusted analyses. Significant P-values are given in \u003cstrong\u003ebold.\u003c/strong\u003e \u003csup\u003ea\u003c/sup\u003eAdjusted for all other variables in the domain or total. \u003csup\u003eb\u003c/sup\u003e Yes/No variable, with \u0026ldquo;No\u0026rdquo; used as reference category.\u003c/p\u003e\n\u003cp\u003eIn the adjusted analyses, female gender was significantly associated with higher agreements on statements that \u003cem\u003efood and mealtimes are perceived as distressing\u003c/em\u003e (P = 0.049) and borderline significant (P = 0.051) for \u003cem\u003efood and mealtimes affect social life and interactions\u003c/em\u003e (P = 0.026). Higher age was significantly associated with a lower degree of agreement on statements that \u003cem\u003efood and mealtimes are perceived as distressing\u003c/em\u003e (P = 0.004). Moreover, having a post-graduate degree in an area other than palliative care was significantly associated with lower agreements on statements that \u003cem\u003efood and mealtimes are perceived as distressing\u003c/em\u003e (P = 0.007), while having a 6\u0026ndash;10 years\u0026rsquo; work experience as RN implied lower agreement on statements that \u003cem\u003efood and mealtimes affect social life and interactions\u003c/em\u003e, compared to RNs with 0\u0026ndash;5 years work experience (P = 0.042).\u003c/p\u003e\n\u003cp\u003eOn average, females had a 0.271 points higher agreement on \u003cem\u003efood and mealtimes are perceived as distressing\u003c/em\u003e, and a 0.342 points higher agreement for statements in the domain \u003cem\u003eaffect social life and interactions\u003c/em\u003e. RNs perceived that food and mealtimes were on average 0.012 points less distressing for each additional year old they were, while RNs with a post-graduate degree in an area other than palliative care had a 0.185 points lower agreement with the statement that \u003cem\u003efood and mealtimes are perceived as distressing\u003c/em\u003e. Finally, RNs with a work experience as RN of 6\u0026ndash;10 years on average had a 0.392 points lower agreement on statements that \u003cem\u003efood and mealtimes affect social life and interactions\u003c/em\u003e, compared with RNs having a shorter work experience of 0\u0026ndash;5 years.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eRegistered nurses\u0026rsquo; advice to colleagues\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eMost RNs (90%) answered the open-ended question, and the responses collected ranged from two to 330 words (mean 32 words). The total word count from all responses was 3197 words. Responses to the open-ended question regarding advice to a new colleague mostly pertained to physical dimensions of care, followed by psychological, social, and existential dimensions (Table 4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4.\u003c/strong\u003e RNs\u0026rsquo; (n = 90) advice to new colleagues sorted according to WHO\u0026rsquo;s palliative care dimensions and other dimension, numbers of RNs given answers belonging to each dimension, number of codes, and percentage of text belonging to each dimension.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDimension\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of RNs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of codes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage of text\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003ePalliative care dimensions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePhysical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e69\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSocial\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e29\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePsychological\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eExistential\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePalliative care approach\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe advice regarding the \u003cem\u003ephysical dimension\u003c/em\u003e, described by 61 RNs, included 69 codes that focused on aspects of eating and how to facilitate and maintain eating throughout the illness trajectory. Examples included practical advice such as adjusting size of meals and food options and eliminating physical reasons for inability to eat (ulcers, mycosis, strictures, etc). The \u003cem\u003esocial dimension\u003c/em\u003e, described by 25 RNs, included 29 codes that pertained to advising new colleagues about family interventions, e.g., that family members should be given space to eat together with patients. Responses also highlighted RNs\u0026rsquo; responsibilities to inform and educate families regarding the dying process and reduced food intake. The most common responses covered individual support to family members and that RNs should help families find strategies to navigate food and eating towards the end-of-life. This could be achieved if families could understand physical deterioration during the dying process and that food no longer is necessary. Advice concerning the \u003cem\u003epsychological dimension\u003c/em\u003e, described by 20 RNs, included 21 codes regarding advice to the new colleagues about aspects of enjoyment around food. Several RNs underscored that eating should never be forced and that nagging was negative. Advice regarding the \u003cem\u003eexistential dimension\u003c/em\u003e, described by seven RNs, included nine codes that focused on life experiences and meanings of eating, like keeping death at bay.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA majority (56%) of the responses to the open-ended question pertained advice regarding the \u003cem\u003ephysical dimension.\u003c/em\u003e In contrast, 14% and 9% of the advice pertained to \u003cem\u003ethe social\u003c/em\u003e and \u003cem\u003epsychological dimensions\u003c/em\u003e, respectively. \u003cem\u003eExistential dimensions\u003c/em\u003e were covered by 4%, and palliative care approach in 17% of the text.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the \u003cem\u003eother category,\u003c/em\u003e advice from 10 RNs to new colleagues (20 codes) was given concerning strategies for nursing and how to achieve a palliative care approach. The most common advice was to focus on patients\u0026rsquo; needs and wishes to form care interventions accordingly, emphasizing that \u003cem\u003eperson-centred care\u003c/em\u003e, \u003cem\u003erelief of suffering\u003c/em\u003e, and \u003cem\u003efamily caregivers are central\u003c/em\u003e. Using attributes such as humility and respect was also encouraged.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo summarize the qualitative data, the physical dimension pertained to practical advice, such as adjusting size of meals and food options, and eliminating physical reasons for inability to eat. The psychological dimension pertained to reactions and emotions such as frustration or sadness. The social dimension pertained to social interactions such as not eating together or not eating the same food and the existential dimension pertained to thoughts of starvation and food as life sustaining. Data not related to these dimensions comprised descriptions concerning the palliative care approach.\u0026nbsp;\u003c/p\u003e"},{"header":"4. Discussion ","content":"\u003cp\u003eThis study presents an initial attempt to study RNs’ perceptions about food and mealtimes in relation to specialist palliative care. The RNs in this study agreed that food and mealtimes in palliative care causes psycho-social distress for patients and families. Female gender was significantly associated with higher agreements on statements that \u003cem\u003efood and mealtimes are perceived as distressing\u003c/em\u003e and \u003cem\u003eaffect social life and interactions\u003c/em\u003e, as well as with overall higher agreements on the 19 statements. On the other hand, higher age among RNs was associated with a lower degree of agreement that \u003cem\u003efood and mealtimes are perceived as distressing\u003c/em\u003e. Furthermore, RNs strongly agreed that they should actively work with food and mealtimes at the end of life in \u003cem\u003ehelping patients and families to accept that it is common to stop eating when death is near\u003c/em\u003e. Advice to new colleagues was dominated by physical aspects of care. Fewer RNs suggested advice related to care dimensions with psychological, social, or existential connotations. Support in embracing a palliative care approach was encouraged in general terms.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults in perspective\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePalliative care philosophy and practice guidelines do emphasize the multidimensional nature of palliative care, comprising physical, psychological, social, and existential needs (12, 44, 45), and a holistic approach to care has been advocated since the early days of the hospice movement (46). Nonetheless, our results show that operationalizing a holistic approach in palliative care nursing seems to present a challenge. The RNs in this study were experienced, well-educated clinicians and may thus represent a normative care culture with regards to food and mealtimes in palliative care. In other words, chances are that new colleagues are socialized into the same norm, potentially focusing on physical aspects of care and consequently neglecting, either consciously or by omission, psychological, social, and existential aspects of care. A recent meta-analysis of RCTs underscores that integrated, holistic palliative care improves patients’ abilities to cope with physical and psychological burdens of cancer, thus leading to overall better well-being (44, 47). A recent meta-synthesis of coping strategies for patients with uncurable illness, confirms that holistic care is crucial (48). There is ample evidence to suggest that education and training programs that emphasize the importance of psychological, social, and existential needs in parallel with physical needs is called for. We suggest that these programs should include practical strategies for integrating these aspects into daily care practices of individual RNs, for example as a fellowship or trainee year with mentoring from (49).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe acknowledge that providing integrated, holistic care is challenging in various healthcare settings (50-52). In palliative care, principles of patient-centered and compassionate care are consistently emphasized (17), reiterating that specialist pallative nursing takes patients’ and families’ individual needs, wishes and resourses into account when planning care and during care provision. During the 21st century, we have seen a paradigm shift in palliative care, from focusing on end-of-life care for cancer patients in institutions to broader perspectives including concepts such as life-limiting disease and early intervention (3, 12), health-promoting palliative care (53), and life-enhancing care (54). Thus, the conceptual transitions in palliative care involve moving from terminal diseases and cancer to advanced progressive chronic diseases and limited life expectancy, encompassing all chronic progressive illnesses and conditions. Subsequently, the scope of specialist nursing practice has shifted from symptom management and death is approaching, to well-being and promoting strategies for living with a chronic illness. This shift may not yet have influenced clinical practice regarding food and nutrition in palliative care. Existing guidelines primarily focus on physiological needs (55, 56).\u0026nbsp;Policy changes are needed to directly support holistic care practices. We advocate for the inclusion of comprehensive guidelines on nutritional care in national palliative care standards, ensuring that multiple dimensions of patient well-being are addressed.\u003c/p\u003e\n\u003cp\u003eA review indicates that RNs are aware of the illness trajectory, with dying and death affecting patients, families, and care providers (17). In our results, higher age among RNs was associated with a lower degree of agreement that \u003cem\u003efood and mealtimes are perceived as distressing\u003c/em\u003e. Similarly, age was found to affect nursing students’ attitudes towards care of the dying (57). It is unclear whether this is connected to clinical experiences and subsequent personal reflections concerning death and dying or other factors. Benner's (58) novice to expert theory provides a useful framework for understanding the progression of nursing proficiency and its’ impact on holistic nursing practices. Already when patients are admitted to palliative care, RNs know that dying and death are to be expected, even though patients and families may not yet have arrived at the same conclusion (59). RNs are expected to support and inform patients and family, with an imperative to prepare patients and family for a good death. With the diverging understanding and expectations on goals of care between RNs and patients and families, RNs may experience distress since caring for patients and families who are not fully aware of dying is challenging, especially if there are differences or lack of joint goals of care in the healthcare team (60). In the context of palliative care, Benner’s framework (58)) can help explain why experienced RNs might prioritize physical aspects of care. Potentially, RNs in this study focused on physical aspects in relation to food and mealtimes, since there is a multitude of concrete care interventions to try, as suggested by Gillespie and Raftery (61). Their advanced clinical skills allow them to address concrete needs efficiently, while psychological, social, and existential needs may require more nuanced, intuitive approaches that develop over time. In outcomes focused healthcare settings, ‘doing’ nursing interventions that ‘solve’ a physical problem may be preferable to something that takes more time and effort. Research suggests that existential needs may be especially challenging since dying and death is a reality in the near future (62). To be prepared to address existential concerns often involves deep personal reflections on the meaning of life, mortality, and the emotional and spiritual distress associated with the end of life. Nonetheless, provision of specialist palliative care nursing requires engaging with patients and families in creating sensitive, person-centered and individualized support (12). Education and training for individual RNs to operationalize holistic care and developing policy guidelines for nutritional care in palliative care are suggestions to fill the gaps identified by this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eStrengths and limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConstructing a study-specific questionnaire may present a limitation with regards to internal validity (63).\u0026nbsp;However, statements originated with existing literature and the questionnaire was discussed, tested, and reflected on by a multi-professional group and an expert group for its content and face validity before being used. Steps like these are important when constructing a questionnaire (64, 65). Constructing statements based on research is complex and entails a risk, as they may reflect underlying assumptions made by the researcher. Therefore, testing the statements was essential. Participants responses may also vary depending on their prior assumptions, from experiences or knowledge, and this is not captured here.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnother risk is to introduce desirability bias (66) when distributing a questionnaire indicating that there are challenges around food and mealtime. Potentially, RNs may have agreed to participate on those premises, consequently resulting in skewed responses. On the other hand, RNs answered the questions anonymously and could utilize the free text answers for elaboration without any direct influence by researchers. The open-ended question provided RNs with the opportunity to add experiences that were not highlighted in the questionnaire.\u003c/p\u003e\n\u003cp\u003eGiven the low response rate (approximately 21%), no claims of generalization can be made. Nonetheless, 100 persons responded during an ongoing pandemic. Recruiting participants via social media and an association for RNs in palliative care mean that reasons for declining participation were unknown. The two groups might have some overlap, as RNs could potentially be members of both groups, and the exact response rate is thus unknown. Sample bias is possible due to the convenience sampling; however, some significant results were found, and the results can potentially generate hypotheses for future research. One possible explanation to having few responders is that no reminders could be sent out to individual persons. Our sample consisted of RNs with extensive clinical experience, and they were highly educated; many had a post-graduate degree in nursing and were experienced in palliative care, thus further limiting the generalization of the findings. However, the sample potentially does indicate how RNs with specialist education view circumstances around food and mealtimes at the end of life. Initial exploration implies that RNs’ perceptions align with patients’ and families’, indicating awareness of the challenges that patients and families face.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnother aspect to consider is the gender imbalance with 94% of the participants being women. This is somewhat higher than the proportion of female RNs in Sweden at 87% (67). Despite this gender imbalance, statistically significant gender differences were found, with females to a higher degree agreeing that food and mealtimes are perceived as distressing, and that they affect social life and interactions. Although no conclusions can be drawn regarding the clinical importance of these findings based on our study, the results indicate that exploring these differences further may provide gendered nuances of caring practices. A larger sample focusing on whether gender is associated with perceptions of food and mealtimes, or other core aspects of caring, may yield valuable insights. A larger sample may also have detected potential differences between general and specialised palliative care.\u0026nbsp;\u003c/p\u003e"},{"header":"5.\tConclusions ","content":"\u003cp\u003eThe RNs in this study reported that food and mealtimes in palliative care cause distress for patients and families They strongly agreed on the importance of actively addressing issues around food and mealtimes at the end of life, helping patients and families to understand that it is common to stop eating as death approaches. Advice to new colleagues primarily focused on physical aspects of care; with fewer RNs offering guidance on psychological, social, or existential dimensions. These needs may be seen as more challenging to address because they are not as easily remedied. Support in embracing a palliative care approach was encouraged in general terms, aligning with professional competence and development. This study suggests that experienced clinicians offer crucial perspectives for specialist palliative care provision.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank the 100 RNs who took their time and participated. We would also like to thank the researchers, RNs and patients who evaluated the questionnaire for giving critical input when constructing the questionnaire.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe first, second, and last authors contributed to the conception and design. All authors contributed to creating the survey statements. The third author facilitated the data collection. All authors contributed to the analysis and interpretation of the data. All authors contributed to the drafting and critical revision of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe questionnaire statements are included in the article. The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was obtained.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was granted by the the Swedish Ethical Review Authority. Before participation, informed consent procedures were observed. Participants were given written information about the study, including their rights, confidentiality was guaranteed, including data management and presentation of findings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMorgan DH. Rethinking Family Practices. Palgrave Macmillan; 2011.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScott S. Making sense of everyday life. Cambridge: Polity; 2009.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmbl\u0026agrave;s J, Bauer R, Beas E, Callaway M, Connor S, Costa X. Building integrated palliative care programs and services. Collaboration with the World Health Organization Collaborating Centre Public Health Palliative Care Programmes; 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmano K, Baracos VE, Mori N, Okamura S, Yamada T, Miura T, et al. 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From novice to expert: excellence and power in clinical nursing practice. Menlo Park, Calif.: Addison-Wesley; 1984.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBruce A, Sheilds L, Molzahn A, Beuthin R, Schick-Makaroff K, Shermak S. Stories of Liminality: Living With Life-Threatening Illness. J Holist Nurs. 2013;32(1):35\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCorradi-Perini C, Beltr\u0026atilde;o JR, Ribeiro U. Circumstances Related to Moral Distress in Palliative Care: An Integrative Review. Am J Hosp Palliat Care. 2021;38(11):1391\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGillespie S, Menon P, Heidkamp R, Piwoz E, Rawat R, Munos M et al. Measuring the coverage of nutrition interventions along the continuum of care: time to act at scale. BMJ Glob Health. 2019;4(4).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHemberg J, Bergdahl E. Ethical sensitivity and perceptiveness in palliative home care through co-creation. Nurs Eth. 2019;27(2):446\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCreswell JW, Creswell JD. Research design: qualitative, quantitative, and mixed methods approaches. Los Angeles: SAGE; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWaltz CF, Strickland O, Lenz ER. Measurement in nursing and health research. New York: Springer; 2010.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKumar A. Review of the steps for development of quantitative research tools. Adv Pract Nurs 2015; 2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFerrari JR, Cowman SE. Toward a reliable and valid measure of institutional mission and values perception: The DePaul values inventory. J Beliefs Values. 2004;25(1):43\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Board of Health and Welfare. Statistics about registered healthcare professionals 2023 and occupation 2022. Statistik om legitimerad h\u0026auml;lso- och sjukv\u0026aring;rdspersonal 2023 samt arbetsmarknadsstatus 2022. Stockholm Swed, 2023.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"caring, eating problems, end-of-life, families, mealtime, nursing, nutrition, palliative care, patients, perceptions","lastPublishedDoi":"10.21203/rs.3.rs-6128968/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6128968/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eFood and mealtimes are fundamental aspects of human wellbeing, both considering physiological aspects of human life and social interactions. Since registered nurses are key caregivers in palliative care, the aim of this study was to explore registered nurses\u0026rsquo; perceptions of food and mealtimes in palliative care.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eAn exploratory and descriptive cross-sectional, study-specific survey, designed following a systematic review of the literature, was administered online. The study-specific questionnaire consisted of statements about mealtimes in palliative care, and registered nurses were asked to rate the extent to which they agreed with each statement. Using linear regression analysis associations between socio-demographic variables and registered nurses\u0026rsquo; perceptions were explored. Additionally, one open-ended question was analyzed using deductive content analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eRegistered nurses (n\u0026thinsp;=\u0026thinsp;100) had a mean score of 3.3 points on the 4-point scale, indicating that they agreed with the statements about food and mealtimes. Registered nurses agreed to the largest extent with statements concerning r\u003cem\u003eegistered nurses\u0026rsquo; responsibilities\u003c/em\u003e (mean score 3.7 points), and to the least extent regarding food as \u003cem\u003eimproving health and well-being\u003c/em\u003e (mean score 2.8 points). Higher age among registered nurses was statistically significant and associated with a lower degree for \u003cem\u003efood and mealtimes are perceived as distressing\u003c/em\u003e (P\u0026thinsp;=\u0026thinsp;0.004) for patients and family. The open-ended question about \u0026ldquo;what \u003cem\u003eadvice would you give a new colleague about food and mealtimes in palliative care?\u0026rdquo;\u003c/em\u003e pertained to the \u003cem\u003ephysical\u003c/em\u003e (56%), \u003cem\u003ethe social\u003c/em\u003e (14%), the \u003cem\u003epsychological\u003c/em\u003e (9%), and the e\u003cem\u003existential dimensions\u003c/em\u003e (4%), palliative care approach was covered by 17%) of the text.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eRegistered nurses reported that food and mealtimes in palliative care cause distress for patients and families. They strongly agreed on the importance of addressing issues around food and mealtimes at the end of life, helping patients and families to understand that it is common to stop eating as death approaches. Advice to new colleagues often focused on physical care, with fewer registered nurses offering guidance on psychological, social, or existential dimensions. This study highlights the need for support in adopting a holistic approach to palliative care. Experienced clinicians offer crucial perspectives that are vital for specialist palliative care provision.\u003c/p\u003e","manuscriptTitle":"Registered nurses’ perceptions of food and mealtimes in palliative care: a cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-30 08:36:49","doi":"10.21203/rs.3.rs-6128968/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-09T09:26:34+00:00","index":"","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-28T06:03:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-24T05:48:55+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Palliative Care","date":"2025-04-23T17:44:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ad2bcc27-614d-41af-851c-6b39884d7614","owner":[],"postedDate":"April 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-01T16:05:53+00:00","versionOfRecord":{"articleIdentity":"rs-6128968","link":"https://doi.org/10.1186/s12904-025-01935-8","journal":{"identity":"bmc-palliative-care","isVorOnly":false,"title":"BMC Palliative Care"},"publishedOn":"2025-11-29 15:58:51","publishedOnDateReadable":"November 29th, 2025"},"versionCreatedAt":"2025-04-30 08:36:49","video":"","vorDoi":"10.1186/s12904-025-01935-8","vorDoiUrl":"https://doi.org/10.1186/s12904-025-01935-8","workflowStages":[]},"version":"v1","identity":"rs-6128968","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6128968","identity":"rs-6128968","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}