To supplant, supplement or support? Organisational issues for hospices

Enhancing integrated palliative care: what models are appropriate? A cross-case analysis

Background

Effective integration between hospices, palliative care services and other local health care services to support patients with palliative care needs is an important international priority. A previous model suggests that integration involves a cumulative stepped process of engagement with other organisations labelled as ‘support, supplant or supplement’, but the extent to which this model currently applies in the United Kingdom is unknown. We aimed to investigate accounts of hospice integration with local health care providers, using the framework provided by the model, to determine how service users and healthcare professionals perceived palliative care services and the extent of integration experienced.

Methods

Longitudinal organisational case study methods were employed using qualitative serial interviews (interval 3 months) with patients and family carers focusing on how services responded to their needs; and group interviews with health professionals. Data were audio-recorded, transcribed verbatim, and analysed by qualitative content analysis and combined across data sources.

Results

The study focused on four hospices in northern England, including 34 patients (diagnosis: 17 cancer, 10 COPD, 7 heart failure), 65% female, mean age 66 (range 44–89), 13 family carers of these patients (48% partners), and 23 health care professionals. While some care fell short of expectations, all patients reported high levels of satisfaction and valued continuity of care and efficient information sharing. All hospices supported and supplemented local providers, with three hospices also supplanting local provision by providing in-patient facilities.

Conclusion

UK hospices predominantly operate in ways that support and supplement other providers. In addition, some also supplant local services, taking over direct responsibility and funding in-patient care. They all contributed to integration with local services, with greater blurring of boundaries than defined by the original model. Integrated care offers the necessary flexibility to respond to changes in patient needs, however, constraints from funding drivers and a lack of clear responsibilities in the UK can result in shortfalls in optimal service delivery. Integrating hospice care with local healthcare services can help to address demographic changes, predominantly more frail older people, and disease factors, including the needs of those with non-malignant conditions. This model, tested in the UK, could serve as an example for other countries.

At cross-purposes: head-to-head professionalism in not-for-profit pastoral organizations

PURPOSE

The purpose of the paper is to explore the nature and causes of observed tensions among healthcare professionals in not-for-profit organizations such as hospices.

DESIGN/METHODOLOGY/APPROACH

In the paper the narratives collected from discipline leaders in each of five New Zealand hospices are thematically analysed in order to identify consistent and recurring sources of conflict both within and between disciplinary groups.

FINDINGS

The paper finds that motivational differences, poor conflict management, interdisciplinary tensions, divergent attitudes towards volunteerism, strategic planning processes, and poor consultation are identified as some of the starting-points for tensions in the participating hospices.

RESEARCH LIMITATIONS/IMPLICATIONS

The research in this paper is based in New Zealand and uses qualitative methods not intended to produce generalizable results. Nevertheless it was conducted in hospices typical of the Western developed countries and identifies focal points and potential avenues for further exploration.

PRACTICAL IMPLICATIONS

The paper shows that researchers and managers involved in not-for-profit healthcare organization may find the identified issues useful as starting-points for actions to minimise the tensions between and within groups.

ORIGINALITY/VALUE

This paper explores aspects of a rarely discussed issue, and suggests opportunities for more research in this field.

Being a hospice volunteer

The aim of this study was to obtain an understanding of what it means to be a hospice volunteer in a country without a tradition of hospice or palliative volunteer care services. Ten volunteers from three different hospices in Sweden were interviewed. Their narratives were interpreted with a phenomenological hermeneutic method. Three themes were disclosed: motives for becoming involved in hospices, encountering the hospice and encountering the patient. The interpretations disclose a need for the volunteer to be affirmed as a caring person and received in fellowship at the hospice. Positive encounters with a hospice are closely related to personal growth. Volunteers feel rejected if their need for meaning and for belonging to the hospice is not satisfied. This shows that hospices need to set goals in terms of volunteer support, particularly regarding existential issues following the encounter with the hospice and the patient.

The nursing contribution to qualitative research in palliative care 1990-1999: a critical evaluation

BACKGROUND

Qualitative research plays an important part in providing evidence for practice in nursing, and is gaining greater acceptance within medicine. However, questions remain about what criteria are most appropriate for evaluating qualitative research. To date, little systematic evaluation of qualitative research in palliative care has been conducted.

AIMS

This paper is based on a larger study in which we conducted a critical review of qualitative research in palliative care from nursing, medicine, specialist palliative care, sociology, death studies, medical anthropology, and gerontology journals published between 1990 and 1999. The aim of this paper is to present an account of the strengths and weaknesses of qualitative palliative care research in nursing, using data from this review.

METHODS

In the larger study, 138 papers from 50 journals were reviewed critically using a tool developed to assess both content and quality; in one part of this tool reviewers recorded open-ended comments on the strengths and weaknesses of each paper. In this paper, we present a thematic analysis of reviewers' comments on a subgroup of 67 nursing papers from the main review, together with an analysis of comments on 29 papers from a comparison group of death studies, medical anthropology, and sociology journals. Patterns of positive and negative evaluation are identified and used to generate an account of strengths and weaknesses in qualitative palliative care research in nursing.

FINDINGS

Over 40% of the subgroup of papers from nursing journals received positive comments on topic and quality of writing; around 30% received positive comments on contribution to understanding, practical value, and conceptual or theoretical issues. Less than 20% received positive comments on other critical dimensions. Over 40% of nursing papers received negative comments on the link between data, analysis, and findings, other aspects of method and theoretical and conceptual issues. A higher proportion of papers in the comparison group received positive comments on conceptual and theoretical issues and contribution to understanding.

CONCLUSIONS

Nearly half the nursing papers reviewed were judged to be well written or to have a well-chosen topic. However, more than 40% of papers drew negative comments about key methods-related issues. Arguably therefore efforts to improve the quality of research evidence should focus on this area.

The role of volunteers in hospice bereavement support in New Zealand

The purpose of this study was to assess the role of hospice bereavement volunteers in New Zealand. Participants included 34 co-ordinators and 121 volunteers from 26 hospices. Co-ordinators and volunteers were asked about the perceived adequacy of their training, support and deployment. Findings revealed that most volunteers were recruited through personal contact and newspapers. They reported being strongly motivated to help others (88%) and most had previous bereavements (71%). Volunteers provided a wide range of bereavement support within the home and/or hospice. They listed twice as many 'satisfying' compared to 'least satisfying' (442 vs 207) aspects of their work, although 50% reported their work to be emotionally distressing and 28% had problems with 'boundaries'. Two-thirds had generic volunteer training, but only a third had specific training in bereavement. Volunteers appeared to be largely unaware of the need for specialist training, or supervision, which raises issues about the quality of services provided.