Implementation of national palliative care guidelines in Swedish acute care hospitals: A qualitative content analysis of stakeholders’ perceptions

How social workers are positioned and constructed as contributors within national palliative care policies in Sweden: a policy analysis

Background

Palliative care is expected to acknowledge physical, psychological, emotional, spiritual, and social needs, to which social workers can contribute with expertise on recognizing the importance of social relations and how social inequalities impact on individuals. The social work profession faces challenges in claiming their contributions in the hierarchies of medical professions. Polices play an important role in constructing and positioning responsibilities of professions.

Objectives

To analyze how social workers are positioned as contributors to palliative care within national-level policies in Sweden.

Methods and materials

A policy analysis was conducted through a constructivist lens. Data were collected from 10 Swedish national-level policy documents on palliative care.

Results

Three themes emerged: "A natural presence conveying special expertise"; "Emotional conversational support before and after death"; and "Practical support." Overall, social workers' contribution was vaguely described and in similar ways as registered nurses.

Conclusion

In Swedish policies analyzed, social workers' contributions were difficult to differentiate from that of registered nurses, which may complicate their mutual collaborations and cause confusion for individuals at the end of life and their next of kin. Future research on how different professions are positioned within palliative care is needed to reduce risks of role blurring between professions with similar aims. Moreover, given social workers long history of psychosocial knowledge, meanings of this concept need to be further acknowledged.

Barriers and facilitators to national guideline implementation for palliative cancer care in a Danish cross-sectoral healthcare setting: A qualitative study of healthcare professionals' experiences

OBJECTIVE

Patients with incurable cancer should receive general palliative care according to their needs, as provided through collaboration between hospital departments, municipalities, and general practices and as outlined in national guidelines. However, the implementation of general palliative care in Denmark has been inadequate. This study aimed to investigate the healthcare professionals' (HCPs') perceptions on barriers to and facilitators of the implementation of the Danish National Guideline (NG) for general palliative care.

METHODS

This descriptive, qualitative study was guided by the Consolidated Framework for Implementation Research (CFIR). Qualitative focus group and individual interviews were conducted with 23 HCPs. The interview guide, coding, analysis, and reporting of findings were developed within the CFIR framework.

RESULTS

The main barriers to implementing NG were as follows: lack of knowledge about the NG, lack of an implementation plan, and insufficient communication and collaboration across sectors. Important facilitators were as follows: HCP motivation to meet palliative care needs, HCPs with special functions taking responsibility for incorporating NG into local guidelines, and the role of district nurses specialised in palliative care as opinion leaders providing security and continuity for the HCPs working in palliative care.

CONCLUSIONS

To address the needs of patients with incurable cancer, greater efforts are required on implementing general palliative care. Although HCPs in our setting were motivated to improve NG implementation, financial resources and strategies are necessary to ensure sufficient knowledge uptake and accommodate identified barriers in order to translate the NG into practice.

Differences in family caregiver experiences and expectations of end-of-life heart failure care across providers and settings: a systematic literature review

Heart failure impacts patients' quality of life and life expectancy and significantly affects the daily behaviours and feelings of family caregivers. At the end-of-life, the burden for family caregivers depends on their emotional and sentimental involvement, as well as social costs.

OBJECTIVES

The aim of this work is to determine whether and how family caregivers' experiences and expectations vary in relation to the places of care and teams involved in heart failure management.

METHODS

A systematic literature review was conducted, by screening manuscripts dealing with the experience of Family Care Givers' (FCGs) of patients with Advanced Heart failure. Methods and results were reported following the PRISMA rules. Papers were searched through three databases (PubMed, Scopus and Web of Science). Seven topics were used to synthetize results by reporting qualitative information and quantitative evidence about the experience of FCGs in places of care and with care teams.

RESULTS

Thirty-one papers, dealing with the experience of 814 FCGs, were selected for this systematic review. Most manuscripts came from the USA (N = 14) and European countries (N = 13) and were based on qualitative methods. The most common care setting and provider profile combination at the end of life was home care (N = 22) and multiprofessional teams (N = 27). Family caregivers experienced "psychological issues" (48.4%), impact of patients' condition on their life (38,7%) and "worries for the future" (22.6%). Usually, when family caregivers were unprepared for the future, the care setting was the home, and there was a lack of palliative physicians on the team.

DISCUSSION

At the end-of-life, the major needs of chronic patients and their relatives are not health related. And, as we observed, non-health needs can be satisfied by improving some key components of the care management process that could be related to care team and setting of care. Our findings can support the design of new policies and strategies.

Implementation of clinical guidelines in specialized palliative care-results from a national improvement project: A national register-based study

BACKGROUND

Knowledge about the process and the results of the implementation of clinical guidelines to improve palliative care is limited. A national project aimed at improving the quality of life of advanced cancer patients admitted to specialized palliative care services in Denmark by implementing clinical guidelines for the treatment of pain, dyspnea, constipation, and depression.

AIM

To investigate the degree of clinical guideline implementation by evaluating the proportion of patients treated according to guidelines among those who qualified (i.e. reported severe symptom level) before and after the 44 palliative care services implemented the guidelines, and how often different types of interventions were provided.

DESIGN

This is a national register-based study.

SETTING/PARTICIPANTS

Data from the improvement project were stored in and later obtained from the Danish Palliative Care Database. Adult patients with advanced cancer admitted to palliative care between September 2017 and June 2019 who answered the EORTC QLQ-C15-PAL questionnaire were included.

RESULTS

In total 11,330 patients answered the EORTC QLQ-C15-PAL. The proportions of services that implemented the four guidelines ranged 73%-93%. Among services that had implemented guidelines, the proportion of patients receiving interventions was roughly constant over time reaching between 54% and 86% (lowest for depression). Pain and constipation were frequently treated pharmacologically (66%-72%), whereas dyspnea and depression were frequently treated non-pharmacologically (61% each).

CONCLUSIONS

Implementing clinical guidelines was more successful for physical symptoms than for depression. The project generated national data on interventions provided when guidelines were followed, which may be used to understand differences in care and outcomes.

Dying as an issue of public concern: cultural scripts on palliative care in Sweden

In Sweden, palliative care has, over the past decades, been object to policies and guidelines with focus on how to achieve "good palliative care". The aim of this study has been to analyse how experts make sense of the development and the current state of palliative care. Departing from this aim, focus has been on identifying how personal experiences of 'the self' are intertwined with culturally available meta-level concepts and how experts contribute to construct new scripts on palliative care. Twelve qualitative interviews were conducted. Four scripts were identified after analysing the empirical material: 1. script of paths towards working within palliative care; 2. script of desirable and deterrent reference points; 3. script of tensions between improvement and bureaucracy; and 4. script of low status and uncertain definitions. The findings of this study illustrate how experts in complex ways intertwine experiences of 'the self' with meta-levels concepts in order to make sense of the field of palliative care. The participants did not endorse one "right way" of "good" deaths. Instead, palliative care was considered to be located in a complex state where the historical development, consisting of both desirable ideals, death denials and lack of guidelines, and more recent developments of strives towards universal concepts, "improvement" and increased bureaucracy altogether played a significant role for how palliative care has developed and is organised and conducted today.

A novel care guide for personalised palliative care - a national initiative for improved quality of care

Background

Even when palliative care is an integrated part of the healthcare system, the quality is still substandard for many patients and often initiated too late. There is a lack of structured guidelines for identifying and caring for patients; in particular for those with early palliative care needs. A care guide can act as a compass for best practice and support the care of patients throughout their palliative trajectory. Such a guide should both meet the needs of health care professionals and patients and families, facilitating discussion around end-of-life decision-making and enabling them to plan for the remaining time in life. The aim of this article is to describe the development and pilot testing of a novel Swedish palliative care guide.

Methods

The Swedish Palliative Care Guide (S-PCG) was developed according to the Medical Research Council framework and based on national and international guidelines for good palliative care. An interdisciplinary national advisory committee of over 90 health care professionals together with patient, family and public representatives were engaged in the process. The feasibility was tested in three pilot studies in different care settings.

Results

After extensive multi-unit and interprofessional testing and evaluation, the S-PCG contains three parts that can be used independently to identify, assess, address, follow up, and document the individual symptoms and care-needs throughout the whole palliative care trajectory. The S-PCG can provide a comprehensive overview and shared understanding of the patients’ needs and possibilities for ensuring optimal quality of life, the family included.

Conclusions

Based on broad professional cooperation, patients and family participation and clinical testing, the S-PCG provides unique interprofessional guidance for assessment and holistic care of patients with palliative care needs, promotes support to the family, and when properly used supports high-quality personalised palliative care throughout the palliative trajectory. Future steps for the S-PCG, entails scientific evaluation of the clinical impact and effect of S-PCG in different care settings – including implementation, patient and family outcomes, and experiences of patient, family and personnel.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00874-4.

The implementation process of the Confident Birth method in Swedish antenatal education: opportunities, obstacles and recommendations

Antenatal clinics in western Sweden have recently invested in a birth method called Confident Birth. In this study, we investigate midwives' and first line managers' perceptions regarding the method, and identify opportunities and obstacles in its implementation. Semi-structured individual interviews were conducted with ten midwives and five first line managers working in 19 antenatal clinics in western Sweden. The Consolidated Framework for Implementation Research was used in a directed content analysis approach. Intervention Characteristics-such as perceptions about the Confident Birth method-were found to have equipped the midwives with coping strategies that were useful for expecting parents during birth. Outer Setting-the method was implemented to harmonize the antenatal education, and provided a mean for a birth companionship of choice. Inner setting-included time-consuming preparations and insufficient information at all levels, which affected the implementation. Characteristics of individuals-, such as knowledge and believes in the method, where trust in the method was seen as an opportunity, while long experience of teaching other birth preparatory methods, affected how the Confident Birth method was perceived. Process-such as no strategy for ensuring that the core of the method remained intact or plans for guiding its implementation were major obstacles to successful implementation. The findings speak to the importance of adequate planning, time, information and communication throughout the process to have a successful implementation. Based on lessons learned from this study, we have developed recommendations for successful implementation of interventions, such as the Confident Birth, in antenatal care settings.

A Scoping Review of End-of-Life Communication in International Palliative Care Guidelines for Acute Care Settings

CONTEXT

End-of-life communication in acute care settings can be challenging and many patients and families have reported low satisfaction with those conversations.

OBJECTIVE

To explore existing guidelines around palliative care to increase current understanding of end-of-life communication processes applicable to the acute care setting.

METHODS

A scoping review following the method of Arksey and O'Malley was undertaken to identify eligible documents and thematically summarize findings. Web sites of government authorities, departments, and ministries of health as well as palliative care organizations were searched as were MEDLINE, CINAHL (EBSCOhost), EMBASE, Cochrane Library, Joanna Briggs Institute, and PsycINFO databases. Searches were limited to documents published between January 2009 and August 2019 that were nondisease specific and applicable to the acute care setting.

RESULTS

Thirteen guidelines from nine different countries were identified. Thematic analysis produced eight themes: 1) The purpose and process of end-of-life communications, 2) cognitive understanding and language in end-of-life communication, 3) legal aspects of end-of-life communication, 4) conflicts and barriers related to end-of-life care, 5) end-of-life communication related to medical record documentation, 6) healthcare professionals' responsibilities and collaboration, 7) education and training, and 8) policies, guidelines, and tools for end-of-life communications.

CONCLUSIONS

Palliative and end-of-life guidelines applicable to acute care settings outline the purpose of end-of-life communication and address how, when, and by whom such conversations are best initiated and facilitated. How guidelines are developed and what aspects of communications are included and emphasized may differ across countries related to role differences of physicians and nurses and national laws and regulations.

An Integrative Review of Community Theories Applied to Palliative Care Nursing

The purpose of this integrative review was to appraise the qualitative and quantitative literature for community-level health behavior theory application to palliative care nursing to identify their use and future research implications. To date, there has not been an integrative review of the nursing studies that have used community-level health behavior theory to guide palliative care nursing research. Despite the availability of high-quality care, there continues to be underuse of resources. An integrative review on community-level theory application may provide a more holistic understanding of previous interventions to frame future interventions and research needs. The review was guided by the 5-step framework of Whittemore and Knafl. Relevant literature was searched and appraised. Seven different community-level health behavior theories were found with applications to palliative care nursing, and 16 studies using these theories were identified for discussion. Community-Based Participatory Research was the most used theory. Community-level health behavior theories such as Community-Based Participatory Research have helped build partnerships and activate community resources such as capacity, engagement, and diversity through culturally sensitive training interventions. Further research using these theories in palliative care nursing can realize positive outcomes, particularly in low-income rural areas.

Registered nurses and undergraduate nursing students' attitudes to performing end-of-life care

Registered Nurses (RNs) are in the immediate position to provide End-of-life (EOL) care and counselling for patients and families in various settings. However, EOL-care often creates feelings of uncertainty and inadequacy linked to inexperience, lack of education, and attitude. To identify and describe factors associated with RNs' attitudes towards EOL-care, and to identify whether and how these attitudes differ from undergraduate nursing students' (UNSs) attitudes, a descriptive and comparative, quantitative study was performed. The FATCOD-instrument, focusing on attitude towards EOL-care, was used and the results analysed with descriptive and nonparametric statistics. In total, 287 RNs in 14 different specialist programmes, and 124 UNSs participated. A statistically significant difference (p = 0.032) was found in attitude towards EOL-care based on clinical experience. RNs in "Acute Care" and "Paediatric & Psychiatry Care" specialist programmes had a less positive attitude towards EOL-care (compared to RNs in other specialist programmes), while RNs attending the Palliative Care programme had the most positive attitudes. RNs and UNSs' scores differed statistically significantly in 17 out of 30 FATCOD variables. Finally, the results imply that there is a need for greater emphasis on further continuing education within EOL care for RNs working in all types of clinical specialities to encourage RNs talking about death and to enhance attitudes towards EOL care.

Implementation of a context-specific accreditation assessment tool for affirming quality midwifery education in Bangladesh: a qualitative research study

Background: Only recently did midwifery become a profession in Bangladesh. As such, sufficient quality education, both theory and practice, remains a challenge. In 2018, a context-specific accreditation assessment tool for affirming quality midwifery education was therefore developed and implemented.Objectives: To describe both the positive and negative aspects of the implementation of an accreditation process at midwifery education institutions in Bangladesh and to sketch out areas for possible improvement.Method: Forty focus group discussions were conducted with 276 policymakers, regulatory authorities and educators involved in midwifery education and services in Bangladesh. The Consolidated Framework for Implementation Research (CFIR) was used in a directed content analysis approach.Results: The accreditation assessment tool was developed using a participatory and consensus-building approach, building on existing policies, which resulted in the national ownership of its implementation. Staff from clinical sites were not included in the accreditation process; unless this changes, this will make it difficult for Bangladesh to achieve the set accreditation standards. The accreditation process has improved communication between the midwifery teaching institutions, policymakers and regulatory authorities. Educators started to visit the clinical sites more frequently. The planning process was complex and time-consuming, and emphasis was put on the importance of developing a plan of action for measuring improvements.Conclusion: In the move from the initial assessment of an accreditation process to its implementation, it is essential to make public the results found at all educational institutions. This encourages acceptance, while soliciting feedback and suggestions for future action. Only then can an accreditation process have an impact on the provision of high-quality midwifery education and services. This paper aims to encourage and guide other countries in their development, planning and implementation of a national accreditation process for midwifery education.

No ordinary consultation - a qualitative inquiry of hospital palliative care consultation services

PURPOSE

Considering the great need for palliative care in hospitals, it is essential for hospital staff to have palliative care knowledge. Palliative consultations have been shown to have positive effects on in-hospital care. However, barriers to contact with and uptake of palliative consultation advice are reported, posing a need for further knowledge about the process of palliative consultations. The purpose of this study therefore was to examine how palliative consultations in hospitals are practised, as perceived by consultants and health care professionals on receiving wards.

DESIGN/METHODOLOGY/APPROACH

Focus groups with palliative care consultation services, health care personnel from receiving wards and managers of consultation services. Interpretive description and constant comparative method guided the analysis.

FINDINGS

Variations were seen in several aspects of practice, including approach to practice and represented professions. The palliative consultants were perceived to contribute by creating space for palliative care, adding palliative knowledge and approach, enhancing cooperation and creating opportunity to ameliorate transition. Based on a perception of carrying valuable perspectives and knowledge, a number of consultation services utilised proactive practices that took the initiative in relation to the receiving wards.

ORIGINALITY/VALUE

A lack of policy and divergent views on how to conceptualise palliative care appeared to be associated with variations in consultation practices, tentative approaches and a bottom-up driven development. This study adds knowledge, implying theoretical transferability as to how palliative care consultations can be practised, which is useful when designing and starting new consultation services.

An exploration of how developers use qualitative evidence: content analysis and critical appraisal of guidelines

BACKGROUND

Clinical practice guidelines have become increasingly widely used to guide quality improvement of clinical practice. Qualitative research may be a useful way to improve the quality and implementation of guidelines. The methodology for qualitative evidence used in guidelines development is worthy of further research.

METHODS

A comprehensive search was made of WHO, NICE, SIGN, NGC, RNAO, PubMed, Embase, Web of Science, CNKI, Wanfang, CBM, and VIP from January 1, 2011 to February 25, 2020. Guidelines which met IOM criteria and were focused on clinical questions using qualitative research or qualitative evidence, were included. Four authors extracted significant information and entered this onto data extraction forms. The Appraisal of Guidelines for Research and Evaluation (AGREE II) tool was used to evaluate the guidelines' quality. The data were analyzed using SPSS version 17.0 and R version 3.3.2.

RESULTS

Sixty four guidelines were identified. The overall quality of the guidelines was high (almost over 60%). Domain 1 (Scope and Purpose) was ranked the highest with a median score of 83% (IQ 78-83). Domain 2 (Stakeholder involvement) and Domain 5 (Applicability) were ranked the lowest with median scores of 67% (IQ 67-78) and 67% (IQ 63-73) respectively. 20% guidelines used qualitative research to identify clinical questions. 86% guidelines used qualitative evidence to support recommendations (mainly based on primary studies, a few on qualitative evidence synthesis). 19% guidelines applied qualitative evidence when considering facilitators and barriers to recommendations' implementation. 52% guideline developers evaluated the quality of the primary qualitative research study using the CASP tool or NICE checklist for qualitative studies. No guidelines evaluated the quality of qualitative evidence synthesis to formulate recommendations. 17% guidelines presented the level of qualitative research using the grade criteria of evidence and recommendation in different forms such as I, III, IV, very low. 28% guidelines described the grades of the recommendations supported by qualitative and quantitative evidence. No guidelines described the grade of recommendations only supported by qualitative evidence.

CONCLUSIONS

The majority of the included guidelines were high-quality. Qualitative evidence was mainly used to identify clinical questions, support recommendations, and consider facilitators and barriers to implementation of recommendations'. However, more attention needs to be paid to the methodology. For example, no experts proficient in qualitative research were involved in guideline development groups, no assessment of the quality of qualitative evidence synthesis was included and there was lack of details reported on the level of qualitative evidence or grade of recommendations.

How Effective Is Palliative Care in Improving Patient Outcomes?

OPINION STATEMENT

As palliative care (PC) continues its rapid growth, an emerging body of evidence is demonstrating that its approach of interdisciplinary supportive care benefits many patient populations, including in the oncology setting. As studies and data proliferate, however, questions persist about who, what, why, when, and how PC as well as the ideal time for a PC consult and length of involvement. When comparing outcomes from chemotherapy trials, it is important to consider the dosing regimens used in the various studies. In the same way, it is important to account for the "dose" of the PC interventions utilized across studies, and apples to apples comparisons are needed in order to draw accurate conclusions about PC's benefits. Studies which include a true interdisciplinary PC intervention consistently show improvements in patient quality of life, as well as cost savings, with further study needed for other outcomes. These benefits cannot be extrapolated to care which may be labeled "palliative care," but which does not meet the standard of true interdisciplinary PC. The ultimate question is: Does PC indeed improve outcomes?

Implementation of the integrated palliative care outcome scale in acute care settings – a feasibility study

Objective

Although hospitals have been described as inadequate place for end-of-life care, many deaths still occur in hospital settings. Although patient-reported outcome measures have shown positive effects for patients in need of palliative care, little is known about how to implement them. We aimed to explore the feasibility of a pilot version of an implementation strategy for the Integrated Palliative care Outcome Scale (IPOS) in acute care settings.

Method

A strategy, including information, training, and facilitation to support the use of IPOS, was developed and carried out at three acute care units. For an even broader understanding of the strategy, it was also tested at a palliative care unit. A process evaluation was conducted including collecting quantitative data and performing interviews with healthcare professionals.

Result

Factors related to the design and performance of the strategy and the context contributed to the results. The prevalence of completed IPOS in the patient's records varied from 6% to 44% in the acute care settings. At the palliative care unit, the prevalence in the inpatient unit was 53% and the specialized home care team 35%. The qualitative results showed opposing perspectives concerning the training provided: Related to everyday work at the acute care units and Nothing in it for us at the palliative care unit. In the acute care settings, A need for an improved culture regarding palliative care was identified. A context characterized by A constantly increasing workload, a feeling of Constantly on-going changes, and a feeling of Change fatigue were found at all units. Furthermore, the internal facilitators and the nurse managers’ involvement in the implementation differed between the units.

Significance of the results

The feasibility of the strategy in our study is considered to be questionable and the components need to be further explored to enhance the impact of the strategy and thereby improve the use of IPOS.