Communication issues for the interdisciplinary community palliative care team

Does a novel community-based outpatient palliative care intervention for Parkinson's disease and related disorders improve care? Qualitative results from patients and care partners

BACKGROUND

Palliative care has the potential to address significant unmet needs in people with Parkinson's disease and related disorders, but models that rely on in-person specialty palliative care teams have limited scalability.

AIM

To describe patient and care partner experiences with a novel, community-based palliative care intervention for Parkinson's disease.

DESIGN

Qualitative study embedded in a randomized clinical trial to document participant experiences with a novel palliative care intervention (community neurologist training and remote team-based specialist palliative care). Transcripts were coded and thematically analyzed through a combination of team-based inductive and deductive coding.

SETTING/PARTICIPANTS

Twenty-eight patients and 33 care partners purposively sampled from participants in a randomized clinical trial of a palliative care intervention for Parkinson's disease and related disorders conducted at nine sites.

RESULTS

Benefits of the intervention included management of a wider range of non-motor symptoms, facilitation of conversations about the future, greater engagement with the health care team, and increased referrals to resources. Participants identified areas of improvement, including uptake of palliative care training by community neurologists, additional prognostic counseling, and clarity and timeliness of communication with the multidisciplinary team.

CONCLUSIONS

Clinicians caring for people with Parkinson's disease and related disorders should screen for non-motor symptoms, provide regular prognostic counseling, and refer to specialty palliative care services earlier in the course of illness. Future interventions should be designed to promote uptake of palliative care training by community neurologists and further optimize referral to and coordination with in-person or remote specialty palliative teams.

Information sharing challenges in end-of-life care: a qualitative study of patient, family and professional perspectives on the potential of an Electronic Palliative Care Co-ordination System

OBJECTIVES

To explore current challenges in interdisciplinary management of end-of-life care in the community and the potential of an Electronic Palliative Care Co-ordination System (EPaCCS) to facilitate the delivery of care that meets patient preferences.

DESIGN

Qualitative study using interviews and focus groups.

SETTING

Health and Social Care Services in the North of England.

PARTICIPANTS

71 participants, 62 health and social care professionals, 9 patients and family members.

RESULTS

Four key themes were identified: information sharing challenges; information sharing systems; perceived benefits of an EPaCCS and barriers to use and requirements for an EPaCCS. Challenges in sharing information were a source of frustration for health and social care professionals as well as patients, and were suggested to result in inappropriate hospital admissions. Current systems were perceived by participants to not work well-paper advance care planning (ACP) documentation was often unavailable or inaccessible, meaning it could not be used to inform decision-making at the point of care. Participants acknowledged the benefits of an EPaCCS to facilitate information sharing; however, they also raised concerns about confidentiality, and availability of the increased time and resources required to access and maintain such a system.

CONCLUSIONS

EPaCCS offer a potential solution to information sharing challenges in end-of-life care. However, our findings suggest that there are issues in the initiation and documentation of end-of-life discussions that must be addressed through investment in training in order to ensure that there is sufficient information regarding ACP to populate the system. There is a need for further qualitative research evaluating use of an EPaCCS, which explores benefits and challenges, uptake and reasons for disparities in use to better understand the potential utility and implications of such systems.

Factors Enabling Shared Care with Primary Healthcare Providers in Community Settings: The experiences of Interdisciplinary Palliative Care Teams

Interdisciplinary palliative care (PC) teams experience a number of barriers in their efforts to establish and maintain shared care partnerships with primary health care providers (PHCPs) in caring for patients in community settings. A qualitative study was undertaken in southern Ontario to examine how teams negotiate barriers in order to share mutual responsibility for patients with PHCPs (i.e., family physicians and community nurses). Over a one-year period, focus group interviews (n=15) were conducted with five teams to explore their experiences to better understand the factors that enable shared care. Using a conceptual framework put forth by Williams et al. (2010), the findings reveal that teams circumvent local level barriers through four enabling factors: team characteristics, geography, adaptation of practice, and relationship building. Understanding these factors and strategies to foster them will assist other jurisdictions wanting to establish a similar shared care service delivery model.

Patients' and carers' perspectives of palliative care in general practice: A systematic review with narrative synthesis

BACKGROUND

General practitioners have overall responsibility for community care, including towards end of life. Current policy places generalists at the centre of palliative care provision. However, little is known about how patients and carers understand the general practitioner's role.

AIMS

To explore patient and carer perspectives of (1) the role of the general practitioner in providing palliative care to adult patients and (2) the facilitators and barriers to the general practitioner's capacity to fulfil this perceived role.

DESIGN

Systematic literature review and narrative synthesis.

DATA SOURCES

Seven electronic databases (MEDLINE, Embase, PsycINFO, BNI, CINAHL, Cochrane and HMIC) were searched from inception to May 2017. Two reviewers independently screened papers at title, abstract and full-text stages. Grey literature, guideline, hand searches of five journals and reference list/citation searches of included papers were undertaken. Data were extracted, tabulated and synthesised using narrative, thematic analysis.

RESULTS

A total of 25 studies were included: 14 employed qualitative methods, 8 quantitative survey methods and 3 mixed-methods. Five key themes were identified: continuity of care, communication between primary and secondary care, contact and accessibility, communication between general practitioner and patient, and knowledge and competence.

CONCLUSION

Although the terminology and context of general practice vary internationally, themes relating to the perceived role of general practitioners were consistent. General practitioners are considered well placed to provide palliative care due to their breadth of clinical responsibility, ongoing relationships with patients and families, and duty to visit patients at home and coordinate healthcare resources. These factors, valued by service users, should influence future practice and policy development.

Teamwork in primary palliative care: general practitioners' and specialised oncology nurses' complementary competencies

BACKGROUND

Generalists such as general practitioners and district nurses have been the main actors in community palliative care in Norway. Specialised oncology nurses with postgraduate palliative training are increasingly becoming involved. There is little research on their contribution. This study explores how general practitioners (GPs) and oncology nurses (ONs) experience their collaboration in primary palliative care.

METHODS

A qualitative focus group and interview study in rural Northern Norway, involving 52 health professionals. Five uni-professional focus group discussions were followed by five interprofessional discussions and six individual interviews. Transcripts were analysed thematically.

RESULTS

The ideal cooperation between GPs and ONs was as a "meeting of experts" with complementary competencies. GPs drew on their generalist backgrounds, including their often long-term relationship with and knowledge of the patient. The ONs contributed longitudinal clinical observations and used their specialised knowledge to make treatment suggestions. While ONs were often experienced and many had developed a form of pattern recognition, they needed GPs' competencies for complex clinical judgements. However, ONs sometimes lacked timely advice from GPs, and could feel left alone with sick patients. To avoid this, some ONs bypassed GPs and contacted palliative specialists directly. While traditional professional hierarchies were not a barrier, we found that organization, funding and remuneration were significant barriers to cooperation. GPs often did not have time to meet with ONs to discuss shared patients. We also found that ONs and GPs had different strategies for learning. While ONs belonged to a networking nursing collective aiming for continuous quality improvement, GPs learned mostly from their individual experience of caring for patients.

CONCLUSIONS

The complementary competences and autonomous roles of a specialised nurse and a general practitioner represented a good match for primary palliative care. When planning high-quality teamwork in primary care, organizational barriers to cooperation and different cultures for learning need consideration.

Systematic review of the effectiveness, barriers and facilitators to general practitioner engagement with specialist secondary services in integrated palliative care

The general practitioner (GP) has a critical role in an integrated model of palliative care as they often know the patient and carer well, are experts in generalist care and have knowledge of health and social services in the community. Specialist palliative services have insufficient capacity to meet demand and those with non-cancer terminal conditions and those from rural and remote areas are underserved. Research has focused on improving access to palliative care by engaging the GP with specialist secondary services in integrated palliative care.

OBJECTIVES

(1) Evaluate the effectiveness of interventions designed to engage GPs and specialist secondary services in integrated palliative care; and (2) identify the personal, system and structural barriers and facilitators to integrated palliative care.

METHOD

MEDLINE, EMBASE and CINAHL were searched. Any study of a service that engaged the GP with specialist secondary services in the provision of palliative care was included. GP engagement was defined as any organised cooperation between the GP and specialist secondary services in the care of the patient including shared consultations, case conferences that involved at least both the GP and the specialist clinician and/or other secondary services, and/or any formal shared care arrangements between the GP and specialist services. The specialist secondary service is either a specialist palliative service or a service providing specialist care to a palliative population. A narrative framework was used to describe the findings.

RESULTS

17 studies were included. There is some evidence that integrated palliative care can reduce hospitalisations and maintain functional status. There are substantial barriers to providing integrated care. Principles and facilitators of the provision of integrated palliative care are discussed.

CONCLUSIONS

This is an emerging field and further research is required assessing the effectiveness of different models of integrated palliative care.

General practice and specialist palliative care teams: an exploration of their working relationship from the perspective of clinical staff working in New Zealand

With the future focus on palliative and end-of-life care provision in the community, the role of the general practice team and their relationship with specialist palliative care providers is key to responding effectively to the projected increase in palliative care need. Studies have highlighted the potential to improve co-ordination and minimise fragmentation of care for people living with palliative care need through a partnership between generalist services and specialist palliative care. However, to date, the exact nature of this partnership approach has not been well defined and debate exists about how to make such partnerships work successfully. The aim of this study was to explore how general practice and specialist palliative care team (SPCT) members view their relationship in terms of partnership working. Five focus group discussions with general practices and SPCT members (n = 35) were conducted in 2012 in two different regions of New Zealand and analysed using a general inductive approach. The findings indicate that participants' understanding of partnership working was informed by their identity as a generalist or specialist, their existing rules of engagement and the approach they took towards sustaining the partnership. Considerable commitment to partnership working was shown by all participating teams. However, their working relationship was based primarily on trust and personal liaison, with limited formal systems in place to enable partnership working. Tensions between the cultures of 'generalism' and 'specialism' also provided challenges for those endeavouring to meet palliative care need collaboratively in the community. Further research is required to better understand the factors associated with successful partnership working between general practices and specialist palliative care in order to develop robust strategies to support a more sustainable model of community palliative care.

Communication between office-based primary care providers and nurses working within patients' homes: an analysis of process data from CAPABLE

AIMS AND OBJECTIVES

To examine themes of communication between office-based primary care providers and nurses working in private residences; to assess which methods of communication elicit fruitful responses to nurses' concerns.

BACKGROUND

Lack of effective communication between home health care nurses and primary care providers contributes to clinical errors, inefficient care delivery and decreased patient safety. Few studies have described best practices related to frequency, methods and reasons for communication between community-based nurses and primary care providers.

DESIGN

Secondary analysis of process data from 'Community Aging in Place: Advancing Better Living for Elders (CAPABLE)'.

METHODS

Independent reviewers analysed nurse documentation of communication (phone calls, letters and client coaching) initiated for 70 patients and analysed 45 letters to primary care providers to identify common concerns and recommendations raised by CAPABLE nurses.

RESULTS

Primary care providers responded to 86% of phone calls, 56% of letters and 50% of client coaching efforts. Primary care providers addressed 86% of concerns communicated by phone, 34% of concerns communicated by letter and 41% of client-raised concerns. Nurses' letters addressed five key concerns: medication safety, pain, change in activities of daily living, fall safety and mental health. In letters, CAPABLE nurses recommended 58 interventions: medication change; referral to a specialist; patient education; and further diagnostic evaluation.

CONCLUSIONS

Effective communication between home-based nurses and primary care providers enhances care coordination and improves outcomes for home-dwelling elders. Various methods of contact show promise for addressing specific communication needs.

RELEVANCE TO CLINICAL PRACTICE

Nurses practicing within patients' homes can improve care coordination by using phone calls to address minor matters and written letters for detailed communication. Future research should explore implementation of Situation, Background, Assessment and Recommendation in home care to promote safe and efficient communication. Nurses should empower patients to address concerns directly with providers through use of devices including health passports.

Integrated palliative care in Europe: a qualitative systematic literature review of empirically-tested models in cancer and chronic disease

BACKGROUND

Integrated Palliative Care (PC) strategies are often implemented following models, namely standardized designs that provide frameworks for the organization of care for people with a progressive life-threatening illness and/or for their (in)formal caregivers. The aim of this qualitative systematic review is to identify empirically-evaluated models of PC in cancer and chronic disease in Europe. Further, develop a generic framework that will consist of the basis for the design of future models for integrated PC in Europe.

METHODS

Cochrane, PubMed, EMBASE, CINAHL, AMED, BNI, Web of Science, NHS Evidence. Five journals and references from included studies were hand-searched. Two reviewers screened the search results. Studies with adult patients with advanced cancer/chronic disease from 1995 to 2013 in Europe, in English, French, German, Dutch, Hungarian or Spanish were included. A narrative synthesis was used.

RESULTS

14 studies were included, 7 models for chronic disease, 4 for integrated care in oncology, 2 for both cancer and chronic disease and 2 for end-of-life pathways. The results show a strong agreement on the benefits of the involvement of a PC multidisciplinary team: better symptom control, less caregiver burden, improvement in continuity and coordination of care, fewer admissions, cost effectiveness and patients dying in their preferred place.

CONCLUSION

Based on our findings, a generic framework for integrated PC in cancer and chronic disease is proposed. This framework fosters integration of PC in the disease trajectory concurrently with treatment and identifies the importance of employing a PC-trained multidisciplinary team with a threefold focus: treatment, consulting and training.

Addressing Methodological Challenges in Large Communication Data Sets: Collecting and Coding Longitudinal Interactions in Home Hospice Cancer Care

In this article, we present strategies for collecting and coding a large longitudinal communication data set collected across multiple sites, consisting of more than 2000 hours of digital audio recordings from approximately 300 families. We describe our methods within the context of implementing a large-scale study of communication during cancer home hospice nurse visits, but this procedure could be adapted to communication data sets across a wide variety of settings. This research is the first study designed to capture home hospice nurse-caregiver communication, a highly understudied location and type of communication event. We present a detailed example protocol encompassing data collection in the home environment, large-scale, multisite secure data management, the development of theoretically-based communication coding, and strategies for preventing coder drift and ensuring reliability of analyses. Although each of these challenges has the potential to undermine the utility of the data, reliability between coders is often the only issue consistently reported and addressed in the literature. Overall, our approach demonstrates rigor and provides a "how-to" example for managing large, digitally recorded data sets from collection through analysis. These strategies can inform other large-scale health communication research.

Walk the Doc Talk

There is limited research on interdisciplinary communication between lactation consultants (International Board Certified Lactation Consultant [IBCLC]) and other healthcare professionals. An online survey assessed how healthcare professionals (physicians, surgeons, and alternative practitioners) perceive lactation consultants and what language, forms of communication, and practices are helpful. Participants (N = 75) indicated mostly positive experiences. Negative experiences included lack of communication or dissatisfaction with experience or outcome. Breastfeeding terms were, on average, “somewhat clear,” and several were correlated with perceived adequacy of breastfeeding knowledge. Participants indicated that communications from lactation consultants should include a plan for follow-up, an outline of the safety and rationale for use of potentially unfamiliar treatments, and contact information. The preferred form of communication varied. Improving interdisciplinary communication and collaboration will likely result in better support for breastfeeding dyads.

Improving Communication and Collaboration Between Lactation Consultants and Doctors for Better Breastfeeding Outcomes

The goal of this review is to evaluate the most effective methods of professional interaction, collaboration, and communication between lactation consultants and other healthcare professionals for optimal patient care. The literature revealed that for effective interprofessional communication, lactation consultants must communicate and promote a clear understanding of breastfeeding challenges, their solutions, how lactation consultants can help establish and maintain a positive breastfeeding experience for both mother and baby, preferred modes of communication, as well as the common terminology used by lactation consultants.

Improving Palliative Care Team Meetings

Increasing demands on palliative care teams point to the need for continuous improvement to ensure teams are working collaboratively and efficiently. This quality improvement initiative focused on improving interprofessional team meeting efficiency and subsequently patient care. Meeting start and end times improved from a mean of approximately 9 and 6 minutes late in the baseline period, respectively, to a mean of 4.4 minutes late (start time) and ending early in our sustainability phase. Mean team satisfaction improved from 2.4 to 4.5 on a 5-point Likert-type scale. The improvement initiative clarified communication about patients’ plans of care, thus positively impacting team members’ ability to articulate goals to other professionals, patients, and families. We propose several recommendations in the form of a team meeting “toolkit.”

Bridging Silos

Canadian family physicians (FPs) and home health staff (HHS) experience significant barriers to collaboration regarding patients whose needs are complex. This study used mixed methods to examine whether pre-scheduled, structured audio-conferencing could improve patient-related collaboration between physicians and HHS. The number of shared patients and contacts was collected across three phases: baseline, pre-intervention, and intervention. Interviews with FPs and focus groups with HHS were conducted post-intervention. Mixed effects Poisson regressions for count data, and content analysis for interview and focus group data, were used. No statistically significant “intervention” effect was observed in either the number of shared patients or the average patient contacts. Physicians participating in at least one audio-conference had a lower patient contact rate than the rest of the intervention group and controls. Qualitative data suggested that audio-conferences led to fewer contacts due to more efficient communication.

The association between subcultures and resistance to change – in a Swedish hospital clinic

Purpose

– The purpose of this paper is to explore the different subcultures and the employees’ preparedness for change at an orthopaedic clinic in a university hospital in Sweden.

Design/methodology/approach

– Surveys were sent out to 179 nurses and physicians. The survey included the two instruments Organisational Values Questionnaire and resistance to change (RTC) Scale.

Findings

– The results suggest a dominance of a human relations culture, i.e. flexibility, cohesion and trust, in the orthopaedic clinic. These characteristics seemed to decrease RTC. Opposite to this, planning, routines and goal setting appeared to increase change-resistant behaviour.

Practical implications

– By predicting potential obstacles in a certain context prior to a change process, resources can be used in a more optimal way. An instrument that pinpoints the culture of a particular healthcare setting may be a useful tool in order to anticipate the possible outcome of change.

Originality/value

– The rational goal/internal processes dimension exerted a stronger association with RTC than in earlier studies. Deeply rooted standards and routinised care models, governed by work schedules, could be an obstacle to introducing a care model based on the individual needs of the patient. There was, however, a surprisingly low RTC. The results are contrary to the accepted understanding of public organisations known to be slow to change.

PaTz groups for primary palliative care: reinventing cooperation between general practitioners and district nurses in palliative care: an evaluation study combining data from focus groups and a questionnaire

BACKGROUND

PaTz (an acronym for 'PAlliatieve Thuis Zorg'; palliative care at home) is an intervention to improve palliative care provision and strengthen the generalist knowledge of palliative care. In PaTz general practitioners and district nurses meet on a regular basis to identify patients with palliative care needs and to discuss care for these patients. This study explores experiences with regard to collaboration between general practitioners and district nurses, and perceived benefits of and barriers for implementation of PaTz.

METHODS

This study is conducted within the primary care setting. Participants were 24 general practitioners who filled in a questionnaire, and seven general practitioners, five district nurses and two palliative care consultants who attended one of two focus groups.

RESULTS

PaTz led to improved collaboration. Participants felt informational and emotional support from other PaTz participants. Also they felt that continuity of care was enhanced by PaTz. Practical recommendations for implementation were: meetings every 6 to 8 weeks, regular attendance from both general practitioners and district nurses, presence of a palliative care consultant, and a strong chairman.

CONCLUSIONS

PaTz is successful in enhancing collaboration in primary palliative care and easy to implement. Participants felt it improved continuity of care and knowledge on palliative care. Further research is needed to investigate whether patient and carer outcomes improve.

Organisational culture and change: implementing person-centred care

PURPOSE

The purpose of this paper is to explore the connection between organisational cultures and the employee's resistance to change at five hospital wards in Western Sweden. Staff had experienced extensive change during a research project implementing person-centred care (PCC) for patients with chronic heart failure.

DESIGN/METHODOLOGY/APPROACH

Surveys were sent out to 170 nurses. The survey included two instruments--the Organisational Values Questionnaire (OVQ) and the Resistance to Change Scale (RTC).

FINDINGS

The results indicate that a culture with a dominating focus on social competence decreases "routine seeking behaviour", i.e. tendencies to uphold stable routines and a reluctance to give up old habits. The results indicate that a culture of flexibility, cohesion and trust negatively covariate with the overall need for a stable and well-defined framework.

PRACTICAL IMPLICATIONS

An instrument that pinpoints the conditions of a particular healthcare setting can improve the results of a change project. Managers can use instruments such as the ones used in this study to investigate and plan for change processes.

ORIGINALITY/VALUE

Earlier studies of organisational culture and its impact on the performance of healthcare organisations have often investigated culture at the highest level of the organisation. In this study, the culture of the production units--i.e. the health workers in different hospital wards--was described. Hospital wards develop their own culture and the cultures of different wards are mirrored in the hospital.

Factors supporting good partnership working between generalist and specialist palliative care services: a systematic review

BACKGROUND

The care that most people receive at the end of their lives is provided not by specialist palliative care professionals but by generalists such as GPs, district nurses and others who have not undertaken specialist training in palliative care. A key focus of recent UK policy is improving partnership working across the spectrum of palliative care provision. However there is little evidence to suggest factors which support collaborative working between specialist and generalist palliative care providers.

AIM

To explore factors that support partnership working between specialist and generalist palliative care providers.

DESIGN

Systematic review.

METHOD

A systematic review of studies relating to partnership working between specialist and generalist palliative care providers was undertaken. Six electronic databases were searched for papers published up until January 2011.

RESULTS

Of the 159 articles initially identified, 22 papers met the criteria for inclusion. Factors supporting good partnership working included: good communication between providers; clear definition of roles and responsibilities; opportunities for shared learning and education; appropriate and timely access to specialist palliative care services; and coordinated care.

CONCLUSION

Multiple examples exist of good partnership working between specialist and generalist providers; however, there is little consistency regarding how models of collaborative working are developed, and which models are most effective. Little is known about the direct impact of collaborative working on patient outcomes. Further research is required to gain the direct perspectives of health professionals and patients regarding collaborative working in palliative care, and to develop appropriate and cost-effective models for partnership working.

Palliative care case conferencing involving general practice: an argument for a facilitated standard process

Objective. To discuss the results of a qualitative analysis of the group dynamics of General Practitioner (GP)-led case conferences for palliative care patients, where the GP becomes the care coordinator. Two outcomes are sought: (1) raise the understanding of this type of case conferencing for palliative care patients; and (2) recommend improvements to this process that will positively affect its efficacy. Methods. Original data is the qualitative component of quantitative and qualitative study of 17 GP-led case conferences for palliative care patients. Data were analysed using Carney’s Ladder of Analytical Abstraction. Results. Analysis produced four persistent themes: ambiguity of purpose; ambiguity of role; lack of information; and involvement of multiple interconnected and dynamic groups. These themes are a natural result of the case conferencing process that occurred during the study. Conclusion. Case conferences were inherently uncertain and complex. Complexity results from the range of people and groups interacting with the patient before the case conference who do not attend the conference. Uncertainty results from a lack of direction, leadership and agreed outcomes against which the conference can be structured and measured. A standard process facilitated by someone other than the GP and containing necessary information would offer a better chance of optimising this process. What is known about the topic? Little is known of the group dynamics that occur during these case conferences. What does this paper add? This paper adds a first assessment of the group dynamics of the process and discloses issues that will need to be addressed if this type of case conferencing is to be optimised. What are the implications for practitioners? Understanding of fundamental issues with the process.

Team networking in palliative care

“If you want to travel quickly, go alone. But if you want to travel far, you must go together”. African proverb. The delivery of palliative care is often complex and always involves a group of people, the team, gathered around the patient and those who are close to them. Effective communication and functional responsive systems of care are essential if palliative care is to be delivered in a timely and competent way. Creating and fostering an effective team is one of the greatest challenges for providers of palliative care. Teams are organic and can be life giving or life sapping for their members.

Role-based access in a unified electronic patient record

As modern healthcare shifts towards a patient-centric model, there is an increasing emphasis on teamwork. Legacy healthcare information systems are ill equipped to meet new requirements arising from this change. Many projects have been undertaken to address various aspects of the challenge of supporting patient-centric work. In the UK, development and adoption of a unified electronic patient record (EPR) that serves practitioners across the country is a high priority. This article considers what additional support healthcare teams will require beyond the cross-discipline unified EPR. A system that considers practitioners as part of a patient's care team and which tracks teams and professional roles is proposed and evaluated as a means to provide each practitioner with a view of the EPR appropriate to his/her professional role and to provide improved support for collaboration among team members.

Making sense of health and illness in palliative care: Volunteers' perspectives

Objective:

To encourage communication and contribute to the palliative care movement's need for interdisciplinary care, this article offers to explore the stance of volunteers on two fundamental concepts, “health” and “illness,” as well as their related understanding of “palliative care.” Volunteers' understandings are then compared with the concepts put forth by the Canadian Hospice Palliative Care Association (CHPCA) in its “Model to Guide Hospice Palliative Care.”

Method:

Focus groups with volunteers, and individual interviews with coordinators from five selected palliative care community action organizations from across Canada, are used. A total of 65 participants from three Canadian provinces were interviewed.

Results:

Participants view illness as a subjective, multidimensional, and transformative experience that requires multiple adjustments. It is an impediment to personal equilibrium and a challenge for the terminally ill and their close ones. Health, on the other hand, is a complex phenomenon that consists of physical, psychological, social, and spiritual well-being. For participants, health is most often embodied by a person's capacity to adjust to their challenging circumstances. Both volunteers and coordinators see palliative care as an alternative approach to care that centers on helping patients and their families through their ordeal by offering comfort and respite, and helping patients enjoy their life for as long as possible.

Significance of Results:

Participants describe illness as a destabilizing loss and palliative care as a means to compensate for the numerous consequences this loss brings; their actions reflect these principles and are compatible with the CHPCA model.

A literature review of the role of the specialist palliative care community nurse

This article reviewed international research to obtain an improved understanding of the role defined in the literature as the specialist palliative care community nurse (SPCCN). Developments in cancer treatment and palliative care have lead to improved symptom control and increased prognosis for palliative care patients. In response, there has been a change to the role of the SPCCN indicating a move from a generalized, to specialist, community nurse who provides a consultancy service, thus causing role ambiguity. Within the literature, three themes emerged in defining the role of the community palliative care nurse: communication and collaboration; a clarification of the role; and the role of referral. This review found that there was a blurring of professional boundaries amongst the palliative care team and that the SPCCN has a capacity to coordinate and provide expertise in delivering complex symptom control to patients and their families.

Building empowering partnerships for interprofessional care

While partnership approaches have the potential to achieve cost-effective quality health care, several attributes of the current context make partnerships difficult to achieve. This paper provides an analysis of the socio-cultural, structural and human challenges to building partnerships at both personal and organizational levels, together with an empowering interdisciplinary approach for overcoming these barriers. Premised on empirical evidence, 'flexible client-driven care', currently being tested in the home care sector in Canada, encompasses structures and processes that promote relationship-building and conscientious critical application of individual and collective potential for achieving health care. Strategies for implementing empowering partnership-building at both personal and organizational levels are elaborated, together with the challenges encountered. The practical issues addressed afford insights and ideas for others who may be attempting to achieve similar partnership aims.

An Insight Into the Delivery of a Palliative Approach in Residential Aged Care

Managing the complex care needs of older people is a global concern. General practitioners (GPs) play a pivotal role in aged care, yet little is known about their capacity to provide palliative care in nursing homes. This study aimed to investigate GPs' perceptions and understanding of a palliative approach. A convenience sample of rural GPs ( n = 13) participated in a series of three focus groups undertaken in August, 2005. These focus groups were all audio-taped, transcribed, and analyzed using thematic content analysis. Four key themes emerged: uncertainty about a palliative approach, a need to reorientate providers, the challenges of managing third parties, and making it work and moving forward. These preliminary findings suggest that integrating a palliative approach in aged care requires GPs to have a greater awareness of this paradigm and to be more effectively engaged in multidisciplinary care planning.

Nursing documentation for communicating and evaluating care

AIMS

To investigate the utility of electronic nursing documentation by exploring to what extent and for what purpose general practitioners use nursing documentation and to what extent and in which cases care unit managers use nursing documentation for quality development of care.

BACKGROUND

As health care includes multidisciplinary activities, communication about the care given is essential. To assure delivery of good and safe care, quality development is necessary. The main tool available for communication and quality development is the patient record. In many studies, nursing documentation has been found to be inadequate for this purpose.

DESIGN

This study had a cross-sectional descriptive design.

METHODS

Data were collected by postal questionnaires, one to the general practitioners (n = 544) and one to care unit managers (n = 82) in primary health care. Data were analysed by descriptive statistical and qualitative content analysis.

RESULTS

The general practitioners usually used the nursing record as the foremost source of information for treatment follow-up. The results, however, point out weaknesses and shortcomings in the nursing records, such as difficulties in finding important information because of a huge amount of routine notes. The care unit managers generally (74%) used the record for statistical purposes, while only half of them used it to evaluate care.

CONCLUSION

Nursing records need more clarity and need to be more prominent regarding specific nursing information to fulfil their purpose of transferring information and to constitute a base for quality development of care.

RELEVANCE TO CLINICAL PRACTICE

The results of this study can provide a part of a basis upon which a multi-professional patient record could be developed and which could also function as an alarm to managers at different levels to prioritize the development of nursing documentation.

Implementation and impact of the Gold Standards Framework in community palliative care: a qualitative study of three primary care trusts

The Gold Standards Framework (GSF) has been widely adopted within UK general practices, yet there is little understanding of its impact on the provision of community palliative care services. This study presents data on the anticipation and adoption of the GSF within three Primary Care Trusts in North West England. Forty-seven interviews were conducted with generalist and specialist palliative and primary care professionals. Important aspects of the GSF identified were the patient register, communication and out-of-hours protocols. Positive benefits to professionals included improved communication between professionals and appropriate anticipatory prescribing. Negative aspects included increased nursing workload and the possibility of fewer or later visits for patients. Many respondents believed that the GSF needed local champions to be sustainable. Slow or incomplete adoption was reported. The GSF was recognised as important because it facilitated changes to previously difficult aspects of work between professionals, but few respondents reported direct benefits to patient care.

Access to hospice care: multi-professional specialist perspectives in South Africa

Research addressing the nature of hospice referrals focuses primarily on the effect of late referral and the majority of studies are based in North America. Using health care professionals as key informants, the goal was to describe the hospice referral system used in the Western Cape Province of South Africa from the perspective of nursing sisters, medical doctors, and social workers. Semi-structured interviews with 29 such individuals were conducted at 15 rural, urban and peri-urban sites, exploring their perceptions towards, and experiences with, patient referral to hospice programmes. Interpretative descriptive design allowed for a comprehensive description of the referral process as well as an extension of the data based on the perspectives of the three stakeholder groups. The majority of hospice referrals originated from either community-based clinics or state hospitals. Three main themes, centring around the process of referring, (lack of) standardization, and (lack of) knowledge, arose from the analysis of the transcripts. An interpretation of the themes led to the development of a model describing the ideal hospice referral system for South Africa.

Judgements about fellow professionals and the management of patients receiving palliative care in primary care: a qualitative study

BACKGROUND

Policies emphasise the importance of collaborative working in community palliative care. Collaborations are generally formed through formal and informal referral processes, but little is known about what influences professionals' decisions to refer to such services.

AIM

To explore the influences on referrals within general and specialist community palliative care services.

DESIGN OF STUDY

Qualitative, multiple-case study.

SETTING

Three primary care trusts in the north-west of England.

METHOD

Multiple data collection methods were employed, including documentary analysis, observation of referral team meetings and interviews. This paper primarily reports data from interviews with 47 health professionals, including GPs, district nurses, and specialist palliative care professionals.

RESULTS

Judgements -- positive and negative -- about aspects of fellow professionals' performances appeared to influence referral decisions and ongoing collaboration and care. Attributes upon which these judgements were based included professional responsiveness and communication, respect, working and workload management practices, perceived expertise, and notions of elite practice. The effects of such judgements on referral and healthcare practices were altered by professional "game playing" to achieve professionals' desired outcomes.

CONCLUSION

Palliative care policies and protocols need to take account of these complex and subtle influences on referrals and collaboration. In particular, teamwork and partnership are encouraged within palliative care work, but critical judgements indicate that such partnerships may be difficult or fragile. It is likely that such judgemental attitudes and practices affect many aspects of primary care, not just palliative care.

Interdisciplinary cooperation of GPs in palliative care at home: a nationwide survey in The Netherlands

OBJECTIVE

To investigate the occurrence and predictors of interdisciplinary cooperation of GPs with other caregivers in palliative care at home.

DESIGN

In a prospective study among 96 general practices, the GPs involved identified all dying patients during the study period of 12 months. The GPs received an additional post-mortem questionnaire for each patient who died during the study period, and registered the healthcare providers with whom they cooperated. Multivariable logistic regression analysis was used to identify the predictors of GP cooperation with other caregivers.

SETTING

Second Dutch National Survey in General Practice.

SUBJECTS

A total of 743 patients who received palliative care according to their GP.

MAIN OUTCOME MEASURES

Interdisciplinary cooperation between GP and other healthcare providers.

RESULTS

During the study period, 2194 patients died. GPs returned 1771 (73%) of the questionnaires. According to the GPs, 743 (46%) of their patients received palliative care. In 98% of these palliative care patients, the GP cooperated with at least one other caregiver, with a mean number of four. Cooperation with informal caregivers (83%) was most prevalent, followed by cooperation with other GPs (71%) and district nurses (63%). The best predictors of cooperation between GPs and other caregivers were the patient's age, the underlying disease, and the importance of psychosocial care.

CONCLUSION

In palliative care patients, GP interdisciplinary cooperation with other caregivers is highly prevalent, especially with informal caregivers and other primary care collaborators. Cooperation is most prevalent in younger patients, patients with cancer as underlying disease, and if psychosocial care is important.

Providing a children's palliative care service in the community through fixed-term grants: the staff perspective

BACKGROUND

Children's palliative care services have recently been awarded fixed-term grants, aimed at improving the provision of care for children with life-limiting conditions in the community. We report findings of a qualitative study to investigate the experience of a cohort of community children's nurses from teams involved in setting up or extending community-based children's palliative care services. The purpose of the study was to identify factors that affect service delivery, from the staff perspective, and to suggest ways of promoting their sustainable development.

METHODS

Semi-structured telephone interviews were conducted with 21 nurses from 12 different teams providing palliative care for children at home and in hospices. Participants were questioned about the services they provided and their own roles in that provision. NVIVO qualitative data analysis software was used to explore themes arising from the transcribed recorded interviews.

FINDINGS

Key findings were the importance of physical location in facilitating multidisciplinary communication, the importance of defining role boundaries between existing and new providers of children's palliative care, and the potentially detrimental impact of insecure funding on referral patterns and recruitment to posts. Staff named the opportunity to offer direct 'hands-on' care to families, access to work-based support and networking opportunities as important factors in helping them cope with the stresses involved in managing finite resources and the emotional challenges of their work.

CONCLUSIONS

The maintenance of a mixed caseload with a significant proportion of direct care, provision of ongoing support and clearly defined roles are recommended as means of bolstering the ability of staff to develop their services. The deliberate locating of services to enhance communication between staff and guidance on the preparation of funding applications may further contribute to the sustainability of these services.

Evaluating partnership working: lessons for palliative care

Partnership working in palliative care is being increasingly promoted as the solution to poorly coordinated health and social care services. A key example is the UK National Institute for Clinical Excellence (NICE) guidance on supportive and palliative care. However, partnerships have costs in negotiating, developing and maintaining working relationships and translating these into successful outcomes, so may not always be the best or most effective method of service improvement. This article explores structural, procedural, financial, professional and legitimacy barriers to partnership working. We conclude that these five barriers could be sufficient to destroy emerging partnerships. Nowhere in the NICE guidance on supportive and palliative care are such barriers acknowledged. We suggest that current and projected palliative care partnerships should be critically evaluated against both process and outcome success criteria. Such evaluations must be integral to partnerships, to learn about what makes an effective palliative care partnership, and what affects partnerships have on patient care and outcomes. Partnerships may not be the panacea for issues of fragmentation, and should not be the only solution considered. Lessons should be learnt from the UK's promulgation of partnerships to ensure that these are used appropriately and only where patient benefit can be anticipated.

Criteria for successful multiprofessional cooperation in palliative care teams

INTRODUCTION

Team work is considered a central component of palliative care. Within this comparatively young field of medicine, the emergence of new institutions (eg, palliative care units) highlights the challenge of establishing a completely new team.

METHODS

This study focuses on the factors, which enhance both the success and outcome criteria of good team work from the perception of team members in a palliative care unit. The palliative care team at the University Hospital of Aachen (n = 19) was interviewed 1 year after the unit's startup by the means of semistructured interviews. Interview texts were analysed using qualitative content analysis.

RESULTS

Factors crucial to cooperation in the team members' views were close communication, team philosophy, good interpersonal relationships, high team commitment, autonomy and the ability to deal with death and dying. Moreover, close communication was by far the most frequently mentioned criteria for cooperation. Team performance, good coordination of workflow and mutual trust underpin the evaluation of efficient team work. Inefficient team work is associated with the absence of clear goals, tasks and role delegation, as well as a lack of team commitment.

CONCLUSION

In a new team, close communication is particularly important for staff as they reorientate themselves to the dynamics of a new peer group. The results confirm the overwhelming importance of clarity, commitment and close, positive exchange among team members for successful team work.

The impact of conducting a regional palliative care clinical study

End-of-life care must be informed by methodologically rigorous, high-quality research, but well-documented barriers make the conduct of palliative care clinical trials difficult. With careful consideration to study design and procedures, these barriers are surmountable. This paper discusses the approach used in a large scale, randomised, controlled trial of service-based interventions in a regional palliative care service in South Australia, and the impact of this trial on palliative care research more broadly, the changes to the service in which it was conducted, and on health policy beyond palliative care. The Palliative Care Trial evaluated three interventions in a 2 x 2 x 2 factorial cluster randomised design: case conferences, general practitioner education, and patient education. Main outcomes were performance status, pain intensity, and resource utilisation. A total of 461 patients were enrolled in the study. Pre-study planning and piloting is crucial, and accurately estimated withdrawal and death rates in the study. Other study design elements that facilitated this research included assessment of three interventions at one time, a dedicated recruitment role, a single clinical triage point, embedding data collection into routine clinical assessments, and meaningful outcome measures. Recruitment and retention of participants is possible if barriers are systematically identified and addressed. This study challenged and developed the research culture within our clinical team and subsequently translated into further research.

Interdisciplinary teams in palliative care: a critical reflection

The notion of the interdisciplinary team as integral to the delivery of palliative care emerges clearly and consistently in palliative care philosophy and practice discourses. Many studies have found clear benefits of interdisciplinary palliative care teams. The empirical evidence supporting such teams, however, is not all positive. It is perhaps timely and appropriate to examine critically how palliative care interdisciplinary teams provide optimum support for patients and families. This article examines the notion that palliative care interdisciplinary teams are universally or inevitably effective and identifies potential barriers and constraints to effective teamwork. In particular, it is suggested that there is a need for careful examination of how teams function in the realm of 'psychosocial' care, and ways to look beyond rhetoric are articulated in order to facilitate teams to function more efficiently to provide optimum patient care.

A pragmatic 2×2×2 factorial cluster randomized controlled trial of educational outreach visiting and case conferencing in palliative care—methodology of the Palliative Care Trial [ISRCTN 81117481]

The demand for palliative care is increasing, yet there are few data on the best models of care nor well-validated interventions that translate current evidence into clinical practice. Supporting multidisciplinary patient-centered palliative care while successfully conducting a large clinical trial is a challenge. The Palliative Care Trial (PCT) is a pragmatic 2 x 2 x 2 factorial cluster randomized controlled trial that tests the ability of educational outreach visiting and case conferencing to improve patient-based outcomes such as performance status and pain intensity. Four hundred sixty-one consenting patients and their general practitioners (GPs) were randomized to the following: (1) GP educational outreach visiting versus usual care, (2) Structured patient and caregiver educational outreach visiting versus usual care and (3) A coordinated palliative care model of case conferencing versus the standard model of palliative care in Adelaide, South Australia (3:1 randomization). Main outcome measures included patient functional status over time, pain intensity, and resource utilization. Participants were followed longitudinally until death or November 30, 2004. The interventions are aimed at translating current evidence into clinical practice and there was particular attention in the trial's design to addressing common pitfalls for clinical studies in palliative care. Given the need for evidence about optimal interventions and service delivery models that improve the care of people with life-limiting illness, the results of this rigorous, high quality clinical trial will inform practice. Initial results are expected in mid 2005.

A Comparison of Methodologies from Two Longitudinal Community-Based Randomized Controlled Trials of Similar Interventions in Palliative Care: What Worked and What Did Not?

BACKGROUND

Methodological challenges such as recruitment problems and participant burden make clinical trials in palliative care difficult. In 2001-2004, two community-based randomized controlled trials (RCTs) of case conferences in palliative care settings were independently conducted in Australia--the Queensland Case Conferences trial (QCC) and the Palliative Care Trial (PCT).

DESIGN

A structured comparative study of the QCC and PCT was conducted, organized by known practical and organizational barriers to clinical trials in palliative care.

RESULTS

Differences in funding dictated study designs and recruitment success; PCT had 6 times the budget of QCC. Sample size attainment. Only PCT achieved the sample size goal. QCC focused on reducing attrition through gate-keeping while PCT maximized participation through detailed recruitment strategies and planned for significant attrition. Testing sustainable interventions. QCC achieved a higher percentage of planned case conferences; the QCC strategy required minimal extra work for clinicians while PCT superimposed conferences on normal work schedules. Minimizing participant burden. Differing strategies of data collection were implemented to reduce participant burden. QCC had short survey instruments. PCT incorporated all data collection into normal clinical nursing encounters. Other. Both studies had acceptable withdrawal rates. Intention-to-treat analyses are planned. Both studies included sub-studies to validate new outcome measures.

CONCLUSIONS

Health service interventions in palliative care can be studied using RCTs. Detailed comparative information of strategies, successes and challenges can inform the design of future trials. Key lessons include adequate funding, recruitment focus, sustainable interventions, and mechanisms to minimize participant burden.

Nursing documentation: non-physical dimensions of end-of-life care in acute wards

AIM

to explore discrepancies between nurses' knowledge and their documentation of issues of psychosocial, spiritual and cultural aspects of palliative care, evidenced clearly in recent nursing research into end-of-life care in an acute care, teaching hospital.

DESIGN

the study involved a retrospective patient case-note audit of an opportunistic sample of 20 patients deceased recently and interviews of the two nurses most involved in the care of each patient (n=40).

FINDINGS

this research indicates that nurses in acute care settings often recognize, sometimes explore, but infrequently document psychosocial, spiritual and cultural aspects of care.

CONCLUSION

there is a strong need for: (1) education about both the impact of non-physical dimensions of patients' lives and the effective documentation of these dimensions; and (2) up-grading of documentation tools to better facilitate documentation of non-physical aspects of palliative care.