Experiencing the "caregiver-caregiver" relationship among palliative care nurses: a cross-cultural comparison between France and Quebec through a qualitative study.

"Palliative care is active care delivered in a holistic approach to the person with a serious, progressive or terminal illness" (Société Française d'Accompagnement et de Soins Palliatifs). It is a patient-centered approach that incorporates notions of the helping relationship, communication and interaction with the caregiver (Ratanawongsa, 2012). More commonly referred to as the care relationship (or caregiver-caregiver relationship), this space created between two people is one of the guarantors of the quality of support and well-being of both actors (caregiver and cared-for) (Kornhaber et al., 2016). The quality of the care relationship in the case of end-of-life support is therefore central for both patient and caregiver. On the one hand, for the patient, as it is, among other things, involved in managing uncertainty, helping to make decisions, promoting self-care skills, exchanging information and responding to emotions (Epstein, 2007). These are all fundamental elements that can have an impact on the patient's state of health, enabling him or her to be supported in all dimensions of suffering (Beng et al., 2013; Krawczyk et al., 2018; Mehta & Chan, 2008). On the other hand, for the caregiver, who can experience presence with oneself and the other, listening, compassion and self-compassion (Sinclair et al., 2016), enable him or her to find the right distance from the patient and preserve psychological health (Rushton et al., 2013). However, this care relationship can be altered by factors such as stress or burnout, difficulties in regulating emotions, etc. This observation is particularly salient for caregivers exposed to the end of life, who are regularly confronted with death and the question: "how do you 'be with' what is difficult when accompanying someone at the end of life?". This question concerning the experience of these caregivers, and more specifically of nurses, will be explored through a qualitative exploratory study involving some twenty caregivers. From a cross-cultural perspective, we also ask whether this experience may be influenced by organizational differences and differences in care culture between France and Quebec. The study of this last question will enable us to explore elements influencing the care relationship in a broader context, in another culture, namely Quebec, and within two types of end-of-life support structures (i.e. structures in the public hospital sector and the private sector).

End-of-life accompaniment can engender distress, even compassionate or empathic exhaustion (Nolte et al., 2017), significantly altering caregivers' well-being, and potentially the "caregiver-caregiver" relationship. Studies show that the use of resources such as mindfulness/attentive presence and self-compassion can be protective and beneficial in preventing caregiver distress (Kemper et al., 2019; Scarlet et al, 2017), and improve the helping relationship (McHugh, Kutney-Lee, Cimiotti, Sloane, & Aiken, 2011; Smart et al., 2014). Self-compassion is proving to be an under-explored dimension among caregivers in palliative care (Mills et al., 2018). Therefore, exploring the use of these resources or not in palliative care accompaniment, would allow us to link them with the level of caregiver well-being and the quality of the caregiver-patient relationship.

The first objective of this qualitative study is to take stock by exploring the dimensions essential to the care relationship from the perspective of palliative care nurses and their experiences of confronting the suffering of patients at the end of life. In other words, to better understand the lived experience (at psychological, physical and spiritual levels) of these caregivers when confronting patients' social, physical, psychological and spiritual suffering (Cross, 2019). For this first objective, we will draw on the qualitative studies of Sinclair et al. (2016) and Beng et al. (2013) with people in palliative situations, who extracted several elements and dimensions beneficial to the caregiving relationship that are closely linked to processes of mindfulness (attentive presence to self) and compassion (the intention and action of alleviating the suffering of the other).

The second objective is to explore the differences in nurses' experiences of end-of-life care as a function of the culture to which they belong (i.e., French or Quebecois). Indeed, we can assume that these two cultures differ in aspects relating to caregiver training, types of structures and organization, and potentially in representations and beliefs related to end-of-life.