Implementation science: implications for intervention research in hospice and palliative care

Implementation of Evidence-Based Practice in Long-Term Care: A Scoping Review

OBJECTIVES

To systematically examine implementation strategies within long-term care (LTC) settings. The goal was to identify elements that contribute to adoption and sustainability of evidence-based practices by facilities and frontline health care staff.

DESIGN

Scoping review.

SETTING AND PARTICIPANTS

LTC settings, frontline health care staff and facility administration.

METHODS

A scoping review of the literature across 3 databases was performed. Two researchers independently assessed literature for inclusion against criteria. The researchers independently extracted data for study characteristics following the Action, Actor, Context, Target, Time (AACTT) framework. The quality of included studies was assessed using the Melnyk and Fineout-Overholt Categorization.

RESULTS

Eleven studies examining implementation of a new evidence-based intervention into LTC settings met inclusion requirements. The types of new interventions shared a common classification within the Effective Practice and Organization of Care (EPOC) taxonomy, with all belonging to the Coordination of Care and Management of Care Processes category. All studies had frontline health care staff as the target of implementation strategies. Barriers to implementation included intervention timing in relation to workflow and workload, lack of interest in or skepticism regarding the new intervention, as well as perceptions that the intervention was not within scope or training. Face-to-face communication and asynchronous training were viewed positively, as was having a peer champion available for support.

CONCLUSIONS AND IMPLICATIONS

The results from this review highlight the importance of including communication strategies that use face-to-face delivery and peer champion approaches for successful implementation of new evidence-based interventions. Key implementation strategies also included education tailored to an individual's training and experience level.

Implementation and Effectiveness of Cognitive Behavioral Therapy for Insomnia in Geriatric Primary Care

OBJECTIVES

We evaluated a plan for implementation and effectiveness of cognitive behavioral therapy for insomnia (CBT-I) in geriatric primary care by a geropsychologist.

METHODS

The flow of referrals to a geropsychologist was tracked and, among those eligible and interested in participating, success in deprescribing sleep medications and the effectiveness of CBT-I were documented.

RESULTS

Seventy patients were referred for evaluation of whom 62 were eligible for CBT-I; 34 began CBT-I and 29 completed a full course of treatment. Almost two-thirds of treatment completers were the "old old" (76-84 years) and "oldest old" (85-93 years) with multiple medical problems. Most treatment completers taking sleep medications had them deprescribed at the beginning of treatment and, one year after treatment, did not have them re-prescribed. After CBT-I, two-thirds of patients met the insomnia severity index criteria for response; and three-fifths for remission from insomnia. Further, most patients had sustained improvement in their target insomnia symptom(s) and sleep efficiency.

CONCLUSIONS

CBT-I can be implemented in geriatric primary care with successful deprescribing of sleep medications and meaningful improvement in symptoms of insomnia in a group of older adults of advanced age with multiple medical problems.

CLINICAL IMPLICATIONS

Clinical gerontologists can play an important role in improving late life insomnia.

Using Patient-Centered Dissemination and Implementation Frameworks and Strategies in Palliative Care Settings for Improved Quality of Life and Health Outcomes: A Scoping Review

BACKGROUND

There is a need for patient-provider dissemination and implementation frameworks, strategies, and protocols in palliative care settings for a holistic approach when it comes to addressing pain and other distressing symptoms affecting the quality of life, function, and independence of patients with chronic illnesses. The purpose of this scoping review is to explore patient-centered D&I frameworks and strategies that have been adopted in PC settings to improve behavioral and environmental determinants influencing health outcomes through evidence-based programs and protocols.

METHODS

The five step Arksey and O'Malley's (2005) York methodology was adopted as a guiding framework: (1) identifying research questions; (2) searching for relevant studies; (3) selecting studies relevant to the research questions; (4) charting the data; and (5) collating, summarizing, and reporting results.

RESULTS

Only 6 out of the 38 (16%) included studies applied a D&I theory and/or framework. The RE-AIM framework was the most prominently cited (n = 3), followed by the Diffusion of Innovation Model (n = 2), the CONNECT framework (n = 1), and the Transtheoretical Stages of Change Model (n = 1). The most frequently reported ERIC strategy was strategy #6 "Develop and organize quality monitoring systems", as it identified in all 38 of the included studies.

CONCLUSION

This scoping review identifies D&I efforts to translate research into practice in U.S. palliative care settings. Results may contribute to enhancing future D&I initiatives for dissemination/adaptation, implementation, and sustainability efforts aiming to improve patient health outcomes and personal satisfaction with care received.

Nursing Support for Nausea and Vomiting in Patients With Cancer: A Scoping Review

Nausea and vomiting are symptoms commonly experienced by patients with advanced cancer and have a wide range of causes, including pharmacological interventions. Additionally, multiple factors often simultaneously cause nausea and vomiting. These highly distressing symptoms may be directly or indirectly related to the disease and can significantly impact both the physical and psychological well-being of patients. This study aims to identify the nursing support provided to reduce nausea and vomiting experienced by patients with cancer. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews checklist and Arksey and O'Malley's framework. We searched the PubMed, the Cumulative Index to Nursing and Allied Health Literature, the Cochrane Central Register of Controlled Trials in the Cochrane Library, and the Ichushi-Web of the Japan Medical Abstract Society databases for all content published from the inception of each database through July 31, 2023. A total of 4,625 scientific articles were identified after literature screening. In total, 58 articles were included for full-text review, and 10 articles were finally selected for review. The types of study designs comprised six randomized controlled trials, three prospective observational studies, and one before-after study with no controls. The types of cancers included in the articles were colorectal, breast, lung, pancreatic, gynecological, stomach, and sarcoma. The total sample size of the study population was 793 patients (range = 12-281) for intervention studies and 4,333 patients (range = 20-4,197) for observational studies. Nursing support, extracted from the 10 articles, was classified into the following six types: massage therapy, acupressure, early palliative care, psychosocial support, self-symptom monitoring, and coordinated care. The review yielded six classifications of nursing support for nausea and vomiting in cancer patients. Future research should examine the feasibility of providing nursing support for nausea and vomiting in cancer patients.

Dissemination and Implementation of a Community Health Worker Intervention for Disparities in Palliative Care (DeCIDE PC): a study protocol for a hybrid type 1 randomized controlled trial

BACKGROUND

There are persistent racial and ethnic health disparities in end-of-life health outcomes in the United States. African American patients are less likely than White patients to access palliative care, enroll in hospice care, have documented goals of care discussions with their healthcare providers, receive adequate symptom control, or die at home. We developed Community Health Worker Intervention for Disparities in Palliative Care (DeCIDE PC) to address these disparities. DeCIDE PC is an integrated community health worker (CHW) palliative care intervention that uses community health workers (CHWs) as care team members to enhance the receipt of palliative care for African Americans with advanced cancer. The overall objectives of this study are to (1) assess the effectiveness of the DeCIDE PC intervention in improving palliative care outcomes amongst African American patients with advanced solid organ malignancy and their informal caregivers, and (2) develop generalizable knowledge on how contextual factors influence implementation to facilitate dissemination, uptake, and sustainability of the intervention.

METHODS

We will conduct a multicenter, randomized, assessor-blind, parallel-group, pragmatic, hybrid type 1 effectiveness-implementation trial at three cancer centers across the United States. The DeCIDE PC intervention will be delivered over 6 months with CHW support tailored to the individual needs of the patient and caregiver. The primary outcome will be advance care planning. The treatment effect will be modeled using logistic regression. The secondary outcomes are quality of life, quality of communication, hospice care utilization, and patient symptoms.

DISCUSSION

We expect the DeCIDE PC intervention to improve integration of palliative care, reduce multilevel barriers to care, enhance clinic and patient linkage to resources, and ultimately improve palliative care outcomes for African American patients with advanced cancer. If found to be effective, the DeCIDE PC intervention may be a transformative model with the potential to guide large-scale adoption of promising strategies to improve palliative care use and decrease disparities in end-of-life care for African American patients with advanced cancer in the United States.

TRIAL REGISTRATION

Registered on ClinicalTrials.gov (NCT05407844). First posted on June 7, 2022.

Understanding geriatric models of care for older adults living with HIV: a scoping review and qualitative analysis

BACKGROUND

Advances in Human Immunodeficiency Virus (HIV) treatment have reduced mortality rates and consequently increased the number of individuals with HIV living into older age. Despite this, people aged 50 years and older have been left behind in recent HIV treatment and prevention campaigns, and a gold-standard model of care for this population has not yet been defined. Developing evidence-based geriatric HIV models of care can support an accessible, equitable, and sustainable HIV health care system that ensures older adults have access to care that meets their needs now and in the future.

METHODS

Guided by Arksey & O'Malley (2005)'s methodological framework, a scoping review was conducted to determine the key components of, identify gaps in the literature about, and provide recommendations for future research into geriatric models of care for individuals with HIV. Five databases and the grey literature were systematically searched. The titles, abstracts and full texts of the search results were screened independently in duplicate. Data were analyzed using a qualitative case study and key component analysis approach to identify necessary model components.

RESULTS

5702 studies underwent title and abstract screening, with 154 entering full-text review. 13 peer-reviewed and 0 grey literature sources were included. Most articles were from North America. We identified three primary model of care components that may improve the successful delivery of geriatric care to people living with HIV: Collaboration and Integration; Organization of Geriatric Care; and Support for Holistic Care. Most articles included some aspects of all three components.

CONCLUSION

To provide effective geriatric care to older persons living with HIV, health services and systems are encouraged to use an evidence-based framework and should consider incorporating the distinct model of care characteristics that we have identified in the literature. However, there is limited data about models in developing countries and long-term care settings, and limited knowledge of the role of family, friends and peers in supporting the geriatric care of individuals living with HIV. Future evaluative research is encouraged to determine the impact of optimal components of geriatric models of care on patient outcomes.

Fit for Duty: Lessons Learned from Outpatient and Homebound Hematopoietic Cell Transplantation to Prepare Family Caregivers for Home-Based Care

In the past decade, the demand for home-based care has been amplified by the Coronavirus disease 2019 pandemic. Home-based care has significant benefits for patients, their families, and healthcare systems, but it relies on the often-invisible workforce of family and friend caregivers who shoulder essential health care responsibilities, frequently with inadequate training and support. Hematopoietic cell transplantation (HCT), a potentially curative but intensive treatment for many patients with blood disorders, is being increasingly offered in home-based care settings and necessitates the involvement of family caregivers for significant patient care responsibilities. However, guidelines for supporting and preparing HCT caregivers to effectively care for their loved ones at home have not yet been established. Here, informed by the literature and our collective experience as clinicians and researchers who care for diverse patients with hematologic malignancies undergoing HCT, we provide considerations and recommendations to better support and prepare family caregivers in home-based HCT and, by extension, family caregivers supporting patients with other serious illnesses at home. We suggest tangible ways to screen family caregivers for distress and care delivery challenges, educate and train them to prepare for their caregiving role, and create an infrastructure of support for family caregivers within this emerging care delivery model.

Navigating the application of new innovations: Establishing an indocyanine green lymphography clinic in Australia

Translation of evidence into practice in healthcare is challenging, particularly with new innovations. Indocyanine Green (ICG) lymphography is a novel innovation where the superficial lymphatics are imaged to provide information about lymphoedema diagnosis and to guide individualised therapy for a person's long-term chronic management of lymphoedema, supporting care across the continuum to the community setting. Despite the unique information ICG lymphography provides, the technology itself is complex and highly specialised and currently has limited adoption in clinical practice. This paper sought to determine the barriers and enablers to establishing an ICG lymphography clinic within an outpatient lymphoedema service by exploring staff perceptions and experiences. An interpretive descriptive design was used with semi-structured interviews of key staff participants from a quaternary public hospital six months after ICG lymphography clinic establishment. An interview guide was developed, underpinned by the Consolidated Framework for Implementation Research (CFIR), to guide the inquiry. Interview data were transcribed, inductively coded and analysed to identify themes. All eligible management, clinical and ancillary staff were included (N = 8). Four key themes were identified from the data as essential to implementation success. These were support is critical for implementation; beliefs about the technology; practicalities are achievable; and sustainability for ongoing success. Themes were found to be interrelated and centred around support from staff and the organisation as a critical process facilitator. The study demonstrated an ICG lymphography clinic can be successfully established as part of an outpatient lymphoedema service. Key enablers related to positive staff attitudes and beliefs about ICG lymphography and its application. Future implementation sites may consider that although the complexity of this innovation creates process challenges, the use of an implementation framework can assist in identifying determinants of success for effective implementation to practice.

Understanding public attitudes to death talk and advance care planning in Northern Ireland using health behaviour change theory: a qualitative study

OBJECTIVES

Advance care planning is a key preparatory step in ensuring high-quality palliative and end of life care, and should be considered as a process, beginning with community-level conversations among lay persons. There is, however, indication that death talk among community-dwelling adults is not occurring, and there is a dearth of research examining why this is the case. This study aims to provide the first examination of barriers and facilitators to talking about death and dying among the general population in a UK region (Northern Ireland), and to provide a novel application of health behaviour change theory towards developing a theoretical understanding of the sources of this behaviour.

METHODS

The study involved qualitative analysis of responses (n = 381 participants) to two open-ended questions within a cross-sectional online survey, with recruitment via social media of adults currently living in Northern Ireland. Reflexive thematic analysis was conducted on open text responses per question, with the barriers and facilitators mapped on to health behaviour change models (the Behaviour Change Wheel COM-B and the Theoretical Domains Framework).

RESULTS

The findings evidence a myriad of barriers and facilitators to engaging in death talk, with themes aligning to areas such as lack of acceptance of death in social contexts and fear of upsetting self or others, and a need to improve interpersonal communication skills for facilitating conversations and improve knowledge of the existing services around death and dying. A theoretical understanding of the drivers of death talk is presented with findings mapped across most components of the COM-B Behaviour Change Model and the Theoretical Domains Framework.

CONCLUSIONS

This study contributes to a small but emergent research area examining barriers and facilitators to talking about death and dying. Findings from this study can be used to inform new public health programmes towards empowering adults to have these conversations with others in their community towards upstreaming advance care planning.

Strategies for knowledge translation of a palliative approach outside specialized palliative care services: a scoping review

Objectives

Research suggests palliative care to be translated and integrated in non-specialized palliative care services throughout the palliative care continuum across populations and settings. A need has been identified to build on the existing research literature in order to design strong knowledge translation strategies that can be evaluated in future research. The aim was to map strategies for knowledge translation of a palliative approach to care into non-specialized palliative care services for adult patients. The objectives were to explore the primary research activities, the specific type of knowledge translation strategies used, the research designs and study settings for such evaluations along with the major results thereof, and to identify major research gaps in this area.

Methods

A scoping review was performed to map the volume and characteristics of research literature (project registered in PROSPERO #2018 CRD42018100663). The ten-year period 2010 to 2019 was searched in six major databases for original articles published in English in which the knowledge translation of a palliative approach for adult patients was evaluated in non-specialized palliative healthcare settings, and all type of empirical data-based research designs. We excluded non-English, non-empirical articles, non-evaluation of knowledge translations, specialized palliative care settings, and other types of publications (i.e. non-original articles).

Results

Most of the 183 included articles focused on patients with cancer who were dying in hospitals and in high income countries. Only 13 articles focused on early palliative care. A palette of different strategies was used to implement palliative care in non-specialist palliative settings; no strategy was identified as outstanding. The majority of the articles had unspecified essential components of the research designs.

Conclusion

Previous suggestions for utilization of implementation science for knowledge translation of a palliative approach to care into non-specialized palliative care services are confirmed, and established knowledge translation theories can strengthen the field. To advance this specific field of knowledge, meticulously detailed reporting of studies is required as related to research designs, clarifications of contextual influences and mechanisms at work. Specific systematic reviews and meta-syntheses in the field are merited.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-00929-0.

A translational research framework for nurse practitioners

AIMS

This study aims to explore a proposed translational research continuum for nurse practitioners.

BACKGROUND

Nurse practitioners are acknowledged as clinical leaders responsible for transforming health care delivery. It is important that nurse practitioners contribute to health care knowledge using scientific processes for the implementation of evidence-based practice and evaluation of outcomes of interventions for their patient groups.

EVALUATION

This paper provides a review of translational research literature including implementation science to align nurse practitioner activities to a modified translational research framework.

KEY ISSUES

A translational research framework has the potential to strengthen nursing research in the nurse practitioner role. Adapting an accepted translational research continuum for nurse practitioners places the clinical nursing leaders in an equitable research position with all health care professionals.

IMPLICATIONS FOR NURSING MANAGEMENT

The translational research continuum provides nursing management with a structure to benchmark nursing research. The continuum applies a modern research framework to support research engagement for the nurse practitioner role.

The central role of provider training in implementing resource-stratified guidelines for palliative care in low-income and middle-income countries: Lessons from the Jamaica Cancer Care and Research Institute in the Caribbean and Universidad Católica in Latin America

Individuals in low-income and middle-income countries (LMICs) account for approximately two-thirds of cancer deaths worldwide, and the vast majority of these deaths occur without access to essential palliative care (PC). Although resource-stratified guidelines are being developed that take into account the actual resources available within a given country, and several components of PC are available within health care systems, PC will never improve without a trained workforce. The design and implementation of PC provider training programs is the lynchpin for ensuring that all seriously ill patients have access to quality PC services. Building on the Breast Health Global Initiative's resource-stratified recommendations for provider education in PC, the authors report on efforts by the Jamaica Cancer Care and Research Institute in the Caribbean and the Universidad Católica in successfully developing and implementing PC training programs in the Caribbean and Latin America, respectively. Key aspects of this approach include: 1) fostering strategic academic partnerships to bring additional expertise and support to the effort; 2) careful adaptation of the curriculum to the local context and culture; 3) early identification of feasible metrics to facilitate program evaluation and future outcomes research; and 4) designing PC training programs to meet local health system needs.

PhD programs and the advancement of nursing science

Nurses are well-positioned to be groundbreaking researchers, scientists, leaders, and innovators to improve the health and well-being of individuals, families, and communities. Nurse scientists are needed to contribute to scientific discoveries that inform effective strategies to improve patient care and outcomes and to inform future policies. Thoughtful consideration is required about the preparation of nurse scientists to ensure they are equipped with the knowledge and skill sets to meet the needs of society. Evolving health needs and priority areas of inquiry along with an ever-increasing array of sophisticated methodologies and centrality of interdisciplinary teams to solve complex problems should drive how we prepare PhD students. This paper reflects a panel and subsequent dialogue with nurse leaders at the PhD summit held at the University of Pennsylvania in October 2019. Three aspects of PhD education and the advancement of nursing science are discussed 1) examining important elements to support nurse scientist development; 2) identifying key gaps in science that the discipline needs to address in educating the next generation of nurse scientists; and 3) preparing nurse scientists for the competitive funding environment.

Can Community Health Workers Increase Palliative Care Use for African American Patients? A Pilot Study

PURPOSE

African American patients with cancer underutilize advance care planning (ACP) and palliative care (PC). This feasibility study investigated whether community health workers (CHWs) could improve ACP and PC utilization for African American patients with advanced cancer.

METHODS

African American patients diagnosed with an advanced solid organ cancer (stage IV or stage III disease with a palliative performance score < 60%) were enrolled. Patients completed baseline surveys that assessed symptom burden and distress at baseline and 3 months post-CHW intervention. The CHW intervention consisted of a comprehensive assessment of multiple PC domains and social determinants of health. CHWs provided tailored support and education on the basis of iterative assessment of patient needs. Intervention feasibility was determined by patient and caregiver retention rate above 50% at 3 months.

RESULTS

Over a 12-month period, 24 patients were screened, of which 21 were deemed eligible. Twelve patients participated in the study. Patient retention was high at 3 months (75%) and 6 months (66%). Following the CHW intervention, symptom assessment as measured by Edmonton Symptom Assessment System improved from 33.8 at baseline to 18.8 (P = .03). Psychological distress improved from 5.5 to 4.7 (P = .36), and depressive symptoms from 42.2 to 33.6 (P = .09), although this was not significant. ACP documentation improved from 25% at baseline to 75% at study completion. Sixty-seven percentage of patients were referred to PC, with 100% of three decedents using hospice.

CONCLUSION

Utilization of CHWs to address PC domains and social determinants of health is feasible. Although study enrollment was identified as a potential barrier, most recruited patients were retained on study.

An integrative review to identify evidence of nurse practitioner-led changes to health-care delivery and the outcomes of such changes

AIMS

This study aimed to identify evidence of nurse practitioner-led changes to health-care delivery and the outcomes of such changes.

BACKGROUND

Changing health-care delivery is synonymous with the nurse practitioner role. The literature is critical of the lack of research by nurse practitioners, reporting the effects of a change to health-care delivery.

DESIGN

This study used a systematic integrative review by using Torraco's approach.

DATA SOURCES

Databases Cumulative Index to Nursing and Allied Health Literature, MEDLINE, Web of Science and SCOPUS were searched for peer-reviewed publications from 2000 to 2019.

REVIEW METHODS

A systematic approach was used to screen and analyse the literature. Inclusion/exclusion criteria were applied, and quality appraisal was undertaken by two reviewers.

RESULTS

Eighteen articles were selected. The research projects were across the community and acute care settings. Research methodologies varied including preintervention and postintervention studies, evaluation of quality improvement projects, randomized controlled trial and descriptive studies. Multiple data collection tools were used. Two major themes were identified including evidence-based practice champions and improved patient outcomes.

CONCLUSION

The nurse practitioner role is pertinent toward improving evidence-based practice in clinical settings. Positive patient outcomes and praise for clinical leadership are evident in the literature. Research by nurse practitioners to date has focused on individual services.

Pediatric Psychosocial Standards of Care in action: Research that bridges the gap from need to implementation

OBJECTIVE

To describe innovative models of psychosocial care delivery that align with published Standards of Psychosocial Care of Children with Cancer and their Families, in efforts to bridge the divide between research and practice.

METHODS

The Mattie Miracle Cancer Foundation, in partnership with the American Psychosocial Oncology Society reviewed 22 letters of intent and 13 full grants and awarded small grants to researchers with high quality projects that aimed to implement any of the published 15 Standards of Care. For three of the highest rated funded research projects, we describe the Standard implemented, the novel research design and implementation strategies, and how the research findings might inform the development, implementation, and dissemination of effective solutions for bridging Standard-to-practice gaps.

RESULTS

The first study presented is an innovative eHealth intervention for parents of children with cancer designed to improve family functioning and decrease symptoms of acute distress, anxiety, and posttraumatic stress. The second study addresses the acceptability and feasibility of using daily text message assessments of oral chemotherapy adherence in adolescents and young adults with leukemia, and the third creates a blueprint for providing psychosocial services to siblings, including ways to overcome common implementation barriers.

CONCLUSIONS

Several themes emerged from the studies presented, including (1) attention to barriers to previous attempts at implementation; (2) technology's role in delivering care; (3) the need for stakeholder involvement; and (4) consideration for multi-pronged solutions that address heterogeneity in care settings. Next steps for integrating the Standards of Psychosocial Care into clinical practice are discussed.

Implementation of a Transitional Care Model for Stroke: Perspectives From Frontline Clinicians, Administrators, and COMPASS-TC Implementation Staff

BACKGROUND AND OBJECTIVES

Stroke is a chronic, complex condition that disproportionally affects older adults. Health systems are evaluating innovative transitional care (TC) models to improve outcomes in these patients. The Comprehensive Post-Acute Stroke Services (COMPASS) Study, a large cluster-randomized pragmatic trial, tested a TC model for patients with stroke or transient ischemic attack discharged home from the hospital. The implementation of COMPASS-TC in complex real-world settings was evaluated to identify successes and challenges with integration into the clinical workflow.

RESEARCH DESIGN AND METHODS

We conducted a concurrent process evaluation of COMPASS-TC implementation during the first year of the trial. Qualitative data were collected from 4 sources across 19 intervention hospitals. We analyzed transcripts from 43 conference calls with hospital clinicians, individual and group interviews with leaders and clinicians from 9 hospitals, and 2 interviews with the COMPASS-TC Director of Implementation using iterative thematic analysis. Themes were compared to the domains of the RE-AIM framework.

RESULTS

Organizational, individual, and community factors related to Reach, Adoption, and Implementation were identified. Organizational readiness was an additional key factor to successful implementation, in that hospitals that were not "organizationally ready" had more difficulty addressing implementation challenges.

DISCUSSION AND IMPLICATIONS

Multifaceted TC models are challenging to implement. Facilitators of implementation were organizational commitment and capacity, prioritizing implementation of innovative delivery models to provide comprehensive care, being able to address challenges quickly, implementing systems for tracking patients throughout the intervention, providing clinicians with autonomy and support to address challenges, and adequately resourcing the intervention.

CLINICAL TRIAL REGISTRATION

NCT02588664.

Toward a Practice-Informed Agenda for Hospice Intervention Research: What Are Staff Members' Biggest Challenges?

The translation of evidence-based interventions into routine hospice care is impeded by numerous barriers, including a disconnect between research priorities and clinical care. To inform the development of a more practice-informed agenda for hospice intervention research, our team conducted a qualitative descriptive study, posing the following research questions: 1) How do hospice staff members describe their most significant work-related challenges? and 2) What regulatory changes do hospice staff members report would most improve hospice care? To answer these research questions, we interviewed 22 hospice staff members and then conducted a template analysis of the interview content. In doing so, we identified themes that described challenges in 5 key areas: time, documentation, professional roles, recruitment and retention, and burn-out. In addition, we identified a perceived need among hospice staff members for more regulatory flexibility and clarity. Based on our findings, we conclude that a practice-informed agenda for hospice intervention research includes the development and testing of interventions that increase efficiency, explicitly speak to the humanity of hospice care, and elevate the roles of all members of the interdisciplinary team.

Theory-Based Development of an Implementation Intervention Using Community Health Workers to Increase Palliative Care Use

CONTEXT

Opportunities for the use of palliative care services are missed in African American (AA) communities, despite Level I evidence demonstrating their benefits.

OBJECTIVES

Single-institution and stakeholder-engaged study to design an intervention to increase palliative care use in AA communities.

METHODS

Two-phased qualitative research design guided by the Behavior Change Wheel and Theoretical Domains Framework models. In Phase 1, focus group sessions were conducted to identify barriers and facilitators of palliative care use and the viability of community health workers (CHWs) as a solution. After applying the Behavior Change Wheel and Theoretical Domains Framework to data gathered from Phase 1, Phase 2 consisted of a stakeholder meeting to select intervention content and prioritize modes of delivery.

RESULTS

A total of 15 stakeholders participated in our study. Target behaviors identified were for patients to gain knowledge about benefits of palliative care, physicians to begin palliative care discussions earlier in treatment, and to improve patient-physician interpersonal communication. The intervention was designed to improve patient capability, physician capability, patient motivation, physician motivation, and increase patient opportunities to use palliative care services. Strategies to change patient and physician behaviors were all facilitated by CHWs and included creation and dissemination of brochures about palliative care to patients, empowerment and activation of patients to initiate goals-of-care discussions, outreach to community churches, and expanding patient social support.

CONCLUSION

Use of a theory-based approach to facilitate the implementation of a multi-component strategy provided a comprehensive means of identifying relevant barriers and enablers of CHWs as an agent to increase palliative care use in AA communities.

Methodological challenges in conducting instrumentation research in non-communicative palliative care patients

Well-designed, rigorously implemented instrumentation studies are essential to develop valid, reliable pain assessment tools in non-communicative (non-self-reporting) palliative care patients. When conducting a pain instrumentation study, a research team identified methodologic challenges surrounding informed consent, eligibility criteria, acute pain operational definitions, patient recruitment, missing data, and study-related training during a run-in phase at the beginning of the project and during the conduct of the study. The team dealt with these challenges through identifying root causes, implementing remedial measures, and collecting data to demonstrate improvement or resolution. Effective strategies included obtaining Institutional Review Board (IRB) approval for a waiver of informed consent, modifying eligibility criteria, ensuring that operational definitions and study procedures were consistent with clinical practice, decreasing time from screening to data collection to improve recruitment, increasing study nurse staffing by re-budgeting grant funds, focusing time and resources on high accruing clinical units, revising processes to minimize missing data, and developing detailed training for users of the instrument. With these multi-pronged solutions, the team exceeded the patient accrual target by 25% within the funding period and reduced missing data. While pain instrumentation studies in non-communicative patients have similar challenges to other palliative care studies, some of the solutions may be unique and several are applicable to other palliative care studies, particularly instrumentation research. The team's experience may also be useful for funders and IRBs.

The Perceived Facilitators and Challenges of Translating a Lung Cancer Palliative Care Intervention Into Community-Based Settings

Despite significant progress in implementing palliative care interventions for patients with cancer, few intervention studies seek health care clinicians' input before implementation of these into the community. The purpose of this study was to explore palliative care and oncology clinicians' perspectives on the perceived facilitators and challenges in meeting the quality-of-life needs of patients with lung cancer and family caregivers in community-based settings. The Reach Effectiveness Adoption Implementation Maintenance model for implementation research was used as a framework. This was a multisite qualitative study using focus group and key informant interviews. Nineteen clinicians addressed useful practices and challenges in the following areas: (a) early palliative care, (b) interdisciplinary care planning, (c) symptom management, (d) addressing psychological and social needs, and (e) providing culturally respectful care, including spiritual care. In preparation for the intervention, specific education needs and organizational challenges were revealed. Challenges included timing and staffing constraints, the need for clinician education on palliative care services to increase organizational buy-in, and education in providing spiritual support for patients and family caregivers. This research allowed investigators to understand perceptions of clinicians as they prepared to integrate palliative care in their settings. Hospice and palliative care nurses can be instrumental in implementing palliative care into community practice.

HPNA 2019-2022 Research Agenda: Development and Rationale

Building on the strong work of previous research agendas (2009-2012, 2012-2015, 2015-2018), the Hospice and Palliative Nurses Association Research Advisory Council developed the 2019-2022 Research Agenda in consultation with Hospice and Palliative Nurses Association (HPNA) membership and assessment of major trends in palliative nursing. The HPNA Research Advisory Council identified 5 priority areas and asked subject experts in each area to summarize the state of the science, identify critical gaps, and provide recommendations for future research. This document expands the executive summary published on the HPNA website (www.advancingexpertcare.org/hpna/) and provides supporting evidence for the 2019-2022 recommendations. The 5 priority areas are as follows: (1) pediatric hospice and palliative nursing research; (2) family caregiving; (3) interprofessional education and collaborative practice; (4) big data science, precision health, and nursing informatics; and (5) implementation science.

Caregiver Communication About Cancer: Development of a mhealth resource to support family caregiver communication burden

OBJECTIVE

The aim of this study is to illustrate an evidence-based and theoretically informed mhealth resource (smartphone app) designed to provide communication support for informal cancer caregivers (friends or family members).

METHODS

An eight-step process was conducted: (a) review of existing print resources, (b) selection of theoretical framework for content development, (c) integration of stakeholder feedback and literacy assessment into an alpha print model, (d) review of existing mhealth resources, (e) development of prototype, (f) assessment of caregiver acceptability (n = 5), (g) assessment of quality and perceived impact by cancer providers (n = 26), and (h) acceptability testing with caregivers (n = 6).

RESULTS

Key stakeholders were integrated throughout development and user testing of this iOS smartphone app. The smartphone app consists of talking tips and resources for caregiver communication with the patient, family, far away family, and health care providers, as well as general information sharing features.

CONCLUSIONS

This study demonstrates feasibility and development of an evidence-based and theory-driven mhealth resource to support caregiver communication about cancer. This is the first theory-driven mhealth application created to support the communication burden experienced by cancer caregivers. A larger study is needed to establish the efficacy of the app as an intervention for caregivers.

Interprofessional Perspectives on Providing Spiritual Care for Patients With Lung Cancer in Outpatient Settings

PURPOSE

To explore palliative care and oncology clinicians' perspectives on current challenges and facilitating factors in meeting the spiritual needs of patients with lung cancer and family caregivers. This study was conducted in preparation for a community-based lung cancer palliative care intervention.

PARTICIPANTS & SETTING

19 oncology and palliative care clinicians in three outpatient Kaiser Permanente sites in southern California.

METHODOLOGIC APPROACH

This multisite qualitative study used focus group and key informant interviews. Data were analyzed using content analysis methodology, and a team approach was used to validate findings.

FINDINGS

Clinicians described facilitating factors (interprofessional team support, assessment of spiritual needs, clinician-provided spiritual support, and provision of culturally respectful spiritual care) and challenges (related to providing culturally respectful spiritual care by respecting the patients' spiritual and cultural beliefs in an open way and in advocating for the patients' wishes) they encountered when addressing patient and caregiver spiritual needs.

IMPLICATIONS FOR NURSING

This study demonstrated the need to provide nurses with practical tools, education, and a supportive environment to address patients' and family caregivers' spiritual concerns.

Moving family interventions into the real world: What matters to oncology stakeholders?

BACKGROUND

Family interventions targeting patients and/or informal caregivers are beneficial, but few have been integrated in oncology clinical care. Understanding diverse stakeholder perspectives may inform implementation and dissemination efforts.

METHODS

We are currently conducting a randomized controlled trial of CareSTEPS, a telephone-based intervention for caregivers of advanced lung cancer patients. CareSTEPS seeks to improve caregiver and patient self-care behaviors, quality of life, and satisfaction with care. With an eye toward integrating CareSTEPS into clinical care, semi-structured interviews were conducted with 7 experts in integrated care [practice thought leaders] and 26 individuals representing different oncology stakeholder groups (i.e., potential end users of CareSTEPS including counselors, social workers, nurse specialists, and psychologists) [N = 13], decision-makers, including physicians and administrators [N = 6], and key dissemination partners, including representatives from cancer and caregiving advocacy groups [N = 7]). Questions focused on existing caregiver support services, barriers to integrating care for caregivers in routine patient care, and possible models for clinical uptake and dissemination. Interviews were transcribed and analyzed using directed content analysis.

RESULTS

Stakeholders noted a mismatch between caregiver needs and services offered, and expressed interest in broader service offerings. Barriers for integrating caregiver support into clinical care included inadequate funding, lack of interdisciplinary training among providers, and concern that research-based interventions are often not flexible enough to roll out into clinical practice. To secure buy-in, stakeholders noted the importance of evaluating intervention cost, cost savings, and revenue generation. Possible avenues for dissemination, through bottom-up and top-down (e.g., policy change) approaches, were also discussed.

CONCLUSIONS

Findings highlight the importance of evaluating outcomes important to diverse oncology stakeholder groups to speed translation of research into practice. They also suggest that pragmatic trials are needed that allow for flexibility in the delivery of family interventions and that consider the resource limitations of clinical care.

How to achieve the desired outcomes of advance care planning in nursing homes: a theory of change

BACKGROUND

Advance care planning (ACP) has been identified as particularly relevant for nursing home residents, but it remains unclear how or under what circumstances ACP works and can best be implemented in such settings. We aimed to develop a theory that outlines the hypothetical causal pathway of ACP in nursing homes, i.e. what changes are expected, by means of which processes and under what circumstances.

METHODS

The Theory of Change approach is a participatory method of programme design and evaluation whose underlying intention is to improve understanding of how and why a programme works. It results in a Theory of Change map that visually represents how, why and under what circumstances ACP is expected to work in nursing home settings in Belgium. Using this approach, we integrated the results of two workshops with stakeholders (n = 27) with the results of a contextual analysis and a systematic literature review.

RESULTS

We identified two long-term outcomes that ACP can achieve: to improve the correspondence between residents’ wishes and the care/treatment they receive and to make sure residents and their family feel involved in planning their future care and are confident their care will be according to their wishes. Besides willingness on the part of nursing home management to implement ACP and act accordingly, other necessary preconditions are identified and put in chronological order. These preconditions serve as precursors to, or requirements for, accomplishing successful ACP. Nine original key intervention components with specific rationales are identified at several levels (resident/family, staff or nursing home) to target the preconditions: selection of a trainer, ensuring engagement by management, training ACP reference persons, in-service education for healthcare staff, information for staff, general practitioners, residents and their family, ACP conversations and documentation, regular reflection sessions, multidisciplinary meetings, and formal monitoring.

ONCLUSIONS

The Theory of Change map presented here illustrates a theory of how ACP is expected to work in order to achieve its desired long-term outcomes while highlighting organisational factors that potentially facilitate the implementation and sustainability of ACP. We provide the first comprehensive rationale of how ACP is expected to work in nursing homes, something that has been called for repeatedly.

A Survey to Evaluate Facilitators and Barriers to Quality Measurement and Improvement: Adapting Tools for Implementation Research in Palliative Care Programs

CONTEXT

Although critical for improving patient outcomes, palliative care quality indicators are not yet widely used. Better understanding of facilitators and barriers to palliative care quality measurement and improvement might improve their use and program quality.

OBJECTIVES

Development of a survey tool to assess palliative care team perspectives on facilitators and barriers to quality measurement and improvement in palliative care programs.

METHODS

We used the adapted Consolidated Framework for Implementation Research to define domains and constructs to select instruments. We assembled a draft survey and assessed content validity through pilot testing and cognitive interviews with experts and frontline practitioners for key items. We analyzed responses using a constant comparative process to assess survey item issues and potential solutions. We developed a final survey using these results.

RESULTS

The survey includes five published instruments and two additional item sets. Domains include organizational characteristics, individual and team characteristics, intervention characteristics, and process of implementation. Survey modules include Quality Improvement in Palliative Care, Implementing Quality Improvement in the Palliative Care Program, Teamwork and Communication, Measuring the Quality of Palliative Care, and Palliative Care Quality in Your Program. Key refinements from cognitive interviews included item wording on palliative care team members, programs, and quality issues.

CONCLUSION

This novel, adaptable instrument assesses palliative care team perspectives on barriers and facilitators for quality measurement and improvement in palliative care programs. Next steps include evaluation of the survey's construct validity and how survey results correlate with findings from program quality initiatives.

A Review on Community-Based Knowledge Transfer and Exchange (KTE) Initiatives for Promoting Well-Being in Older Adults

Knowledge transfer and exchange (KTE) processes can facilitate evidence-informed community-based care for seniors, but understanding effective KTE in gerontology is limited. A scoping review was conducted to evaluate the current state of KTE in the community-based sector for seniors. Twelve articles met the inclusion criteria, which addressed a broad variety of topics including caregiving, elder abuse, falls prevention, home-rehabilitation, hospice and dementia care. Studies evaluated KTE practices (n = 8), developed a KTE intervention (n = 3), or explored research uptake (n = 1). Community-based initiatives for seniors informed by KTE processes are scarce, requiring further efforts at the research, practice and policy levels.

Barriers to and facilitators for implementing quality improvements in palliative care - results from a qualitative interview study in Norway

BACKGROUND

Implementation of quality improvements in palliative care (PC) is challenging, and detailed knowledge about factors that may facilitate or hinder implementation is essential for success. One part of the EU-funded IMPACT project (IMplementation of quality indicators in PAlliative Care sTudy) aiming to increase the knowledge base, was to conduct national studies in PC services. This study aims to identify factors perceived as barriers or facilitators for improving PC in cancer and dementia settings in Norway.

METHODS

Individual, dual-participant and focus group interviews were conducted with 20 employees working in different health care services in Norway: two hospitals, one nursing home, and two local medical centers. Thematic analysis with a combined inductive and theoretical approach was applied.

RESULTS

Barriers and facilitators were connected to (1) the innovation (e.g. credibility, advantage, accessibility, attractiveness); (2) the individual professional (e.g. motivation, PC expertise, confidence); (3) the patient (e.g. compliance); (4) the social context (e.g. leadership, culture of change, face-to-face contact); (5) the organizational context (e.g. resources, structures/facilities, expertise); (6) the political and economic context (e.g. policy, legislation, financial arrangements) and (7) the implementation strategy (e.g. educational, meetings, reminders). Four barriers that were particular to PC were identified: the poor general condition of patients in need of PC, symptom assessment tools that were not validated in all patient groups, lack of PC expertise and changes perceived to be at odds with staff's philosophy of care.

CONCLUSION

When planning an improvement project in PC, services should pay particular attention to factors associated with their chosen implementation strategy. Leaders should also involve staff early in the improvement process, ensure that they have the necessary training in PC and that the change is consistent with the staff's philosophy of care. An important consideration when implementing a symptom assessment tool is whether or not the tool has been validated for the relevant patient group, and to what degree patients need to be involved when using the tool.

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.

Implementation and Maintenance of a Community-Based Older Adult Physical Activity Program

PURPOSE OF THE STUDY

We examine facilitators and barriers to the implementation and maintenance of Enhance®Fitness (EF), a group exercise program for older adults, at early-adopter YMCA-affiliated sites, and summarize strategies employed by EF instructors and staff to overcome challenges.

DESIGN AND METHODS

This qualitative study used semi-structured phone interviews with 32 instructors, staff members, and master trainers from 24 different YMCA-affiliated sites. Interviews were digitally recorded, transcribed, and analyzed with a focus on the implementation and maintenance components of the RE-AIM framework.

RESULTS

We identified a series of factors affecting the implementation and maintenance of EF at YMCA-affiliated sites, which can be categorized into program-specific (such as instructor training, the structure of the program, reporting requirements, and insurance coverage), and organizational (such as organizational support and infrastructure for program delivery, champions, and funding to cover the costs of program delivery). Strategies used to overcome challenges associated with these factors include identifying parts of the program that can be adapted, hiring staff and instructors that understand and support the program, and educating staff and instructors about the importance of evidence-based programs and of data collection for program evaluation.

IMPLICATIONS

Assessing the readiness of organizations for program delivery and the match between program goals and the needs of organizations and participants would help facilitate the successful implementation and maintenance of physical activity programs in community settings.

Integrating education, research, and practice in gerontological social work: lessons learned from the reclaiming joy peer support program

The practice-to-research gap has been attributed to many factors, including differing goals and priorities, differing knowledge bases and skill sets, and lack of recognition of limits of agency and community resources. Although many scholars have called for more collaboration between educators, researchers, and practitioners, these challenges can make collaboration difficult. The authors illustrate how the application of the strengths perspective, by acknowledging and building on the strengths and goals of researchers, practitioners, and educators, can help to mitigate some of the barriers that contribute to the research--practice gap and to create more relevant research. The Reclaiming Joy Peer Support Program is offered as a case study in gerontological social work to demonstrate how the strengths perspective can be applied in a real-life research setting.

Barriers and facilitators to implementation of the Liverpool Care Pathway in the Netherlands: a qualitative study

OBJECTIVES

The Liverpool Care Pathway (LCP) is a quality instrument for the dying patient. This study evaluates barriers and facilitators to its implementation in the Netherlands from the perspective of key stakeholders, to inform future implementation processes.

METHODS

An interview study was conducted among 28 stakeholders involved in implementation of the LCP in the Netherlands, followed by a consecutive focus group with 8 interviewees to discuss and validate the findings of the interview study. Interviews were conducted by telephone and the notes taken during the interviews and focus group were transcribed into non-verbatim transcripts. Data collected during the interviews and focus group were evaluated using thematic analysis.

RESULTS

According to the stakeholders, a context analysis prior to implementation was useful to find the appropriate orientation to adequately motivate healthcare professionals as well as management. The main contributing factors were the quality of the LCP (including its evidence-based character and completeness), and that it fitted the needs of healthcare professionals. During the implementation phase, a multidisciplinary project team, competent support and continuous monitoring were identified as important facilitators. Furthermore, for successful implementation, a facilitator working in liaison with others was helpful. To guarantee sustainability of the use of the LCP, it was important to disentangle tasks from the project leader and formally integrate these into the quality systems of the organisation.

CONCLUSIONS

The Dutch experience with large-scale implementation of the LCP has identified important barriers and facilitators to the implementation of a quality instrument within palliative care. To successfully implement such a promising instrument, liaison with others is important. The sense of being part of a process of improvement is valuable, while consolidation of this idea contributes to successful implementation.

Knowledge About Hospice Care and Beliefs About Pain Management

Context:

Among Hispanics, incomplete knowledge about hospice care may explain low rates of utilization and culturally-specific beliefs about pain and pain treatments may contribute to disparities in pain management.

Objectives:

To compare (1) knowledge and attitudes regarding hospice, (2) and beliefs about pain and pain medication between Hispanics and non-Hispanics.

Methods:

A cross-sectional phone-based survey of adults living in the contiguous United States was conducted using randomly selected phone numbers with over-sampling for diversity. Measures assessed knowledge (a 23-item test), attitudes (an 8-item scale), experiences, preferences related to hospice and beliefs regarding pain and pain management.

Results:

123 individuals participated in the survey, 13% of whom were Hispanic. Hispanics were less likely to have heard of hospice are ( p <. 001) and, among those who had, more likely to have inaccurate information about it ( p = .05). Specifically, Hispanics were more likely to report that only individuals over age 65 are eligible for hospice services, which is incorrect (44% vs. 93% of non-Hispanics; p=.001). Only 67% of Hispanics knew that hospice helps family members as well as the dying person. More Hispanics (43%) than non-Hispanics (9.3%) reported that admitting pain is a sign of weakness ( p < .001). A greater proportion of Hispanic respondents agreed that a good patient does not talk about pain ( p = .07): 38% vs. 18% from non-Hispanics.

Conclusion:

Despite the increasing knowledge of hospice care among Hispanics, specific information about the scope of services remains limited. Cultural beliefs about pain management, along with inadequate knowledge of the role of pain management at end of life, persist.

The effect and process evaluations of the national quality improvement programme for palliative care: the study protocol

Background

The nationwide integration of palliative care best practices into general care settings is challenging but important in improving the quality of palliative care. This is why the Dutch National Quality Improvement Programme for Palliative Care has recently been launched. This four-year programme consists of about 70 implementation trajectories of best practices. A large evaluation study has been set up to evaluate this national programme and separate implementation trajectories.

Methods/Design

This paper presents the protocol of the evaluation study consisting of a quantitative effect evaluation and a qualitative process evaluation. The effect evaluation has a pre-test post-test design, with measurements before implementation (month 0) and after implementation (month 9) of a best practice. Patients are eligible if they have a life expectancy of less than six months and/or if they are undergoing palliative treatment and provided they are physically and mentally capable of responding to questionnaires. Bereaved relatives are eligible if they have been involved in the care of a deceased patient who died after a sickbed between six weeks and six months ago. Three types of measurement instruments are used: (1) numerical rating scales for six symptoms (pain, fatigue, breathlessness, obstipation, sadness and anxiety), (2) the Consumer Quality Index Palliative Care - patient version and (3) the version for bereaved relatives.

The process evaluation consists of analysing implementation plans and reports of the implementation, and individual and group interviews with healthcare professionals. This will be done nine to eleven months after the start of the implementation of a best practice.

Discussion

This mixed-method evaluation study gives more insight into the effects of the total programme and the separate implementation trajectories. However, evaluation of large quality improvement programmes is complicated due to changing, non-controlled environments. Therefore, it is important that an effect evaluation is combined with a process evaluation.

Trial registration

NTR-4085