Palliative Approach Remains Lacking in Terminal Hospital Admissions for Chronic Disease Across Rural Settings: Multisite Retrospective Medical Record Audit

INTRODUCTION/AIM

Despite clear benefit from palliative care in end-stage chronic diseases, access is often limited, and rural access largely undescribed. This study sought to determine if a palliative approach is provided to people with chronic disease in their terminal hospital admission.

METHODS

Multisite, retrospective medical record audit, of decedents with a primary diagnosis of chronic lung, heart, or renal failure, or multimorbidity of these conditions over 2019.

RESULTS

Of 241 decedents, across five clinical sites, 143 (59.3%) were men, with mean age 80.47 years (SD 11.509), and diagnoses of chronic lung (n = 56, 23.2%), heart (n = 56, 23.2%), renal (n = 24, 10.0%) or multimorbidity disease (n = 105, 43.6%), and had 2.88 (3.04SD) admissions within 12 months. Outpatient chronic disease care was evident (n = 171, 73.7%), however, contact with a private physician (n = 91, 37.8%), chronic disease program (n = 61, 25.3%), or specialist nurse (n = 17, 7.1%) were less apparent. "Not-for-resuscitation" orders were common (n = 139, 57.7%), however, advance care planning (n = 71, 29.5%), preferred place of death (n = 18, 7.9%), and spiritual support (n = 18, 7.5%) were rarely documented. Referral to and input from palliative services were low (n = 74, 30.7% and n = 49, 20.3%), as was review of nonessential medications or blood tests (n = 86, 35.7%, and n = 78, 32.4%). Opioids were prescribed in 45.2% (n = 109). Hospital site and diagnosis were significantly associated with outpatient care and palliative approach (P<0.001).

CONCLUSIONS

End-of-life planning and specialist palliative care involvement occurred infrequently for people with chronic disease who died in rural hospitals. Targeted strategies are necessary to improve care for these prevalent and high needs rural populations.

Rural general practitioner confidence in diagnosing and managing dementia: A two-stage, mixed methods study of dementia-specific training

INTRODUCTION

Dementias a prevalent chronic healthcare condition affecting 46 million people worldwide and projected to grow in the coming years. Australians living in rural and regional areas often lack access to specialist dementia care, despite greater prevalence relative to metropolitan areas.

OBJECTIVE

This study aimed to explore general practitioners (GP) understanding, confidence and attitudes towards dementia management in the rural context, and design and pilot a dementia-specific training program.

DESIGN

A two-stage, mixed methods design, using qualitative and quantitative methods. Sixteen regional GPs from across Victoria participated in scoping semi-structured interviews. Fourteen separate GPs in the St Anthony Family Medical Practice group in the regional Loddon-Mallee area of Victoria completed the pilot training intervention. Pre- and post-training surveys (n = 10), as well as post-training interviews (n = 10), assessed attitude and knowledge changes.

FINDINGS

Analysis of semi-structured scoping interviews indicated three themes regarding experience of dementia management, including: (1) attitudes to and experiences of dementia; (2) supporting people living with dementia; and (3) knowledge, education and training of dementia. The pilot dementia-specific training was found to improve attitudes (agreement across 24 best-practice indicators improved from 30% to 79%), knowledge (median increase of 2.5/10) and confidence in managing dementia and disclosing dementia diagnoses (median increase 3/10 and 2.75/10, respectively).

DISCUSSION

General practitioners in this study lacked initial confidence in detecting and managing dementia in a rural primary care setting. A targeted training program showed improvements in these areas.

CONCLUSION

Accessible, locally delivered, dementia education has the potential to improve confidence in early detection and management of people with dementia and thereby may address gaps in access to care for people living with dementia in rural settings.

Service Level Characteristics of Rural Palliative Care for People with Chronic Disease

CONTEXT

Despite clear benefit from palliative care in end-stage chronic, non-malignant disease, access for rural patients is often limited due to workforce gaps and geographical barriers.

OBJECTIVES

This study aimed to understand existing rural service structures regarding the availability and provision of palliative care for people with chronic conditions.

METHODS

A cross-sectional online survey was distributed by email to rural health service leaders. Nominal and categorical data were analyzed descriptively, with free-text questions on barriers and facilitators in chronic disease analyzed using qualitative content analysis.

RESULTS

Of 42 (61.7%) health services, most were public (88.1%) and operated in acute (19, 45.2%) or community (16, 38.1%) settings. A total of 17 (41.5%) reported an on-site specialist palliative care team, primarily nurses (19, 59.5%). Nearly all services (41, 95.3%) reported off-site specialist palliative care access, including: established external relationships (38, 92.7%); visiting consultancy (26, 63.4%); and telehealth (18, 43.9%). Perceived barriers in chronic disease included: lack of specific referral pathways (18; 62.1%); negative patient expectations (18; 62.1%); and availability of trained staff (17; 58.6%). Structures identified to support palliative care in chronic disease included: increased staff/funding (20, 75.0%); formalized referral pathways (n = 18, 64.3%); professional development (16, 57.1%); and community health promotion (14, 50%).

CONCLUSION

Palliative care service structure and capacity varies across rural areas, and relies on a complex, at times ad hoc, network of onsite and external supports. Services for people with chronic, non-malignant disease are sparse and largely unknown, with a call for the development of specific referral pathways to improve patient care.

Knowledge and Attitudes of Allied Health Professionals Towards End-Of-Life and Advance Care Planning Discussions With People With COPD: A Cross-Sectional Survey Study

Chronic obstructive pulmonary disease (COPD) is a progressive, life-limiting condition. End-of-life (EOL) and Advance Care Planning (ACP) discussions are essential, yet access and support remain inadequate. Allied health professionals (AHPs) commonly have ongoing relationships with patients and opportunities to discuss care outside acute crises as is considered best practice. Australian and New Zealand AHPs were invited to complete an anonymous, online, cross-sectional survey that aimed to explore knowledge, attitudes and practices, and associated perceived triggers and barriers to EOL and ACP discussions with patients with COPD. Closed survey responses were summarized descriptively and free-text thematically analysed. One hundred and one AHPs (physiotherapists, social workers and occupational therapists) participated. Many held positive attitudes towards ACP but lacked procedural knowledge. Half (50%) of participants routinely discussed EOL care with patients when perceiving this to be appropriate but only 21% actually discussed ACP with the majority of their patients. Many cited lack of training to engage in sensitive EOL discussions, with barriers including: 1) clinician lack of confidence/fear of distressing patients (75%); 2) perceived patient and family reluctance (51%); 3) organizational challenges (28%); and 4) lack of role clarity (39%). AHPs commonly have ongoing relationships with patients with chronic conditions but lack the confidence and role clarity to utilise this position to engage ongoing EOL and ACP discussions. While AHPs may not traditionally consider EOL and ACP discussions as part of their role, it is crucial that they feel prepared to respond if patients broach the topic.

A new model for general practice-led, regional, community-based, memory clinics

Background

Dementia is a major international health issue with high impact on the patient, relatives, and broader society. Routine screening for dementia is limited, despite known benefit of early detection and intervention on quality of care and patient outcomes. Screening is particularly limited in rural and regional areas, despite high burden and projected growth of dementia in these populations. The current study aimed to implement a new general practitioner (GP) led, multidisciplinary, model of care providing dementia detection and referral pathway to a community-based specialist clinic across six regional general practices.

Methods

Cross-sectional analysis of dementia screening and referral characteristics in the St Anthony Family Medical Practices group based in the regional area of Loddon-Mallee, Victoria. Data were collected on demographics and relevant medical history. Cognitive state was assessed using the Mini-Mental State Examination (MMSE), GP Assessment of Cognition (GPCog), and Geriatric Depression Scale (GDS). Referrals and referral outcomes were recorded for geriatrician, psycho-geriatrician, or both.

Results

Eight hundred and eighteenth patients over 65 years were screened, accounting for approximately 24.2% of 65 and over presentations for the practice network. Of those screened, 68.9% were indicated for referral and 30.3% of these were successfully referred. Of the indicated patients who received referrals, 34.2% declined. Many who declined referral had intermediate scores on the cognitive assessments utilized.

Conclusion

Standardised models of care, integrated within community services, are necessary to improve access to early detection, referral and quality management of dementia. The St Anthony Memory Service model will be invaluable in informing future service development, and in particular the development of services for people living with dementia in rural and regional communities.

Understanding potentially avoidable hospitalisations in a rural Australian setting from the perspectives of patients and health professionals: a qualitative study and logic model

Background

Potentially avoidable hospitalisations (PAHs) are proxy measures of effective primary care at a population level. PAHs are higher in rural and disadvantaged areas. This qualitative study sought a deeper understanding of PAHs for chronic health conditions in a rural context from the perspectives of patients and health professionals, and aimed to develop a logic model for rural health services to identify intervention targets.

Methods

Patients with chronic obstructive pulmonary disease, congestive cardiac failure or type 2 diabetes, admitted to a rural hospital in Australia and local health professionals were invited to participate in interviews in late 2019. Semistructured interviews were recorded, transcribed verbatim and thematically analysed. Themes were mapped against a programme logic model developed in a similar study.

Results

patients and 16 health professionals participated. The logic model encompassed patient level (knowledge, skills, health status), provider level (workforce availability, attributes) and system level (clinical pathways) contexts. These contexts influenced key mechanisms of relationships, continuity of care and capacity to offer services. Outcomes included responsive and timely access to care, improved clinical outcomes and resource use. Themes that did not readily map to the logic model included socioeconomic disadvantage and healthcare costs, which influenced affordability and equity of access.

Conclusion

Patients’ complex health and social circumstance, health service access and unclear care pathways were strong themes associated with PAH in this rural context. Patient, provider and system contexts influencing key mechanisms and outcomes need to be understood when designing solutions to address PAHs in rural settings. Ideally, interventions should address the cost of healthcare alongside interventions to enhance relationships, continuity of care and capacity to offer services.

Respiratory Nurses Have Positive Attitudes But Lack Confidence in Advance Care Planning for Chronic Obstructive Pulmonary Disease: Online Survey

Chronic obstructive pulmonary disease (COPD) is a progressive, life-limiting illness. Despite significant symptom burden, access to advance care planning (ACP) and palliative care are limited. Early initiation of ACP enables patients to articulate the values that underpin the decisions they would make if, in the future, they are unable to speak for themselves. Nurses constitute the majority of health care workforce and are well placed to initiate these discussions. This study explored knowledge, attitudes, and practice regarding ACP for patients with COPD among Australian and New Zealand respiratory nurses. A cross-sectional online survey tested knowledge about ACP and canvassed attitudes about current practice. Data were analyzed using descriptive statistics and content analysis of text data. The 112 participating respiratory nurses had substantial knowledge and positive attitudes regarding ACP in COPD; however, they lacked confidence and clarity regarding their role. Despite advances in end-of-life care provision for chronic disease, well-established barriers remained (inadequate training, fear of distressing patients, and time), and discussion triggers were still linked to acute deterioration, diagnosis of severe disease, and patient initiation. Better articulating the role of the respiratory nurse in ACP and building capacity and confidence within this workforce may improve ACP access for people living with COPD.

Barriers to Palliative Care Referral and Advance Care Planning (ACP) for Patients With COPD: A Cross-Sectional Survey of Palliative Care Nurses

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a progressive, life-limiting illness that requires end-of-life care planning, yet remains under-served. Understanding barriers to advance care planning (ACP) from different specialties' perspectives will enable a co-ordinated, cross-disciplinary approach to improving ACP access.

METHODS

Australia and New Zealand palliative care nurses were invited to complete an anonymous online cross-sectional survey. Questions tested knowledge of validated ACP-related practice indicators and canvassed perspectives on barriers to ACP in COPD. Data are described and free-text thematically analyzed.

RESULTS

The 90 participants had high knowledge and positive attitudes to ACP in COPD, however, lacked consensus as to whether patients want to know their prognosis or discuss treatment options and end-of-life wishes. 59% discussed ACP in more than half their patients with COPD, and 77% and 73% routinely initiated or followed-up these discussions. Key barriers included: lack of confidence and training in COPD; reluctance to distress patients and families; referral late in the disease course; lack of consensus on referral timing; and lack of patient and clinician understanding of COPD prognoses. Many reported that lack of consensus in the treating team, paired with prognostic uncertainty, precluded timely ACP engagement.

CONCLUSIONS

Palliative care nurses have substantial knowledge and positive beliefs regarding ACP, however, some beliefs and practices lack alignment with qualitative data on patients' wishes in COPD. While palliative care nurses are well placed to facilitate early implementation for patients with advanced COPD, ACP training and practice guidelines specific to COPD may increase implementation in this life-limiting disease.

Rural chronic disease research patterns in the United Kingdom, United States, Canada, Australia and New Zealand: a systematic integrative review

Background

People living in rural and remote communities commonly experience significant health disadvantages. Geographical barriers and reduced specialist and generalist services impact access to care when compared with metropolitan context. Innovative models of care have been developed for people living with chronic diseases in rural areas with the goal of overcoming these inequities. The aim of this paper was to describe the characteristics and outcomes of studies investigating innovative models of care for people living with chronic disease in rural areas of developed countries where a metropolitan comparator was included.

Methods

An integrative systematic review was undertaken. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method was used to understand the empirical and theoretical data on clinical outcomes for people living with chronic disease in rural compared with metropolitan contexts and their models of care in Australia, New Zealand, United States, Canada and the United Kingdom.

Results

Literature searching revealed 620 articles published in English between 1st January 2000 and 31st March 2019. One hundred sixty were included in the review including 68 from the United States, 59 from Australia and New Zealand (5), 21 from Canada and 11 from the United Kingdom and Ireland. 53% (84) focused on cardiovascular disease; 27% (43) diabetes mellitus; 8% (12) chronic obstructive pulmonary disease; and 13% (27) chronic kidney disease. Mortality was only reported in 10% (16) of studies and only 18% (29) reported data on Indigenous populations.

Conclusions

This integrated review reveals that the published literature on common chronic health issues pertaining to rural and remote populations is largely descriptive. Only a small number of publications focus on mortality and comparative health outcomes from health care models in both urban and non-urban populations. Innovative service models and telehealth are together well represented in the published literature but data on health outcomes is relatively sparse. There is significant scope for further directly comparative studies detailing the effect of service delivery models on the health outcomes of urban and rural populations. We believe that such data would further knowledge in this field and help to break the deadly synergy between increased rurality and poorer outcomes for people with chronic disease.

Benefits of the 'village': a qualitative exploration of the patient experience of COPD in rural Australia

OBJECTIVES

This study sought to explore patients' experiences of living with, and adapting to, chronic obstructive pulmonary disease (COPD) in the rural context. Specifically, our research question was 'What are the barriers and facilitators to living with and adapting to COPD in rural Australia?'

DESIGN

Qualitative, semi-structured interviews. Conversations were recorded, transcribed verbatim and analysed using thematic analysis following the COnsolidated criteria for REporting Qualitative research guidelines.

SETTING

Patients with COPD, admitted to a subregional hospital in Australia were invited to participate in interviews between October and November 2016.

MAIN OUTCOME MEASURES

Themes were identified that assisted with understanding of the barriers and facilitators to living with, and adapting to, COPD in the rural context.

RESULTS

Four groups of themes emerged: internal facilitators (coping strategies; knowledge of when to seek help) and external facilitators (centrality of a known doctor; health team 'going above and beyond' and social supports) and internal/external barriers to COPD self-management (loss of identity, lack of access and clear communication, sociocultural challenges), which were moderated by feelings of inclusion or isolation in the rural community or 'village'.

CONCLUSIONS

Our findings suggest that community inclusion enhances patients' ability to cope and ultimately self-manage COPD. This is facilitated by living in a supportive 'village' environment, and included a central, known doctor and a healthcare team willing to go 'above and beyond'. Understanding, or supplementing, these social networks within the broader social structure may assist people to manage chronic disease, regardless of rural or metropolitan location.

Content and quality of websites supporting self-management of chronic breathlessness in advanced illness: a systematic review

Chronic breathlessness is a common, burdensome and distressing symptom in many advanced chronic illnesses. Self-management strategies are essential to optimise treatment, daily functioning and emotional coping. People with chronic illness commonly search the internet for advice on self-management. A review was undertaken in June 2015 to describe the content and quality of online advice on breathlessness self-management, to highlight under-served areas and to identify any unsafe content. Google was searched from Sydney, Australia, using the five most common search terms for breathlessness identified by Google Trends. We also hand-searched the websites of national associations. Websites were included if they were freely available in English and provided practical advice on self-management. Website quality was assessed using the American Medical Association Benchmarks. Readability was assessed using the Flesch-Kincaid grades, with grade 8 considered the maximum acceptable for enabling access. Ninety-one web pages from 44 websites met the inclusion criteria, including 14 national association websites not returned by Google searches. Most websites were generated in the USA (n=28, 64%) and focused on breathing techniques (n=38, 86%) and chronic obstructive pulmonary disease (n=27, 61%). No websites were found to offer unsafe advice. Adherence to quality benchmarks ranged from 9% for disclosure to 77% for currency. Fifteen (54%) of 28 written websites required grade ⩾9 reading level. Future development should focus on advice and tools to support goal setting, problem solving and monitoring of breathlessness. National associations are encouraged to improve website visibility and comply with standards for quality and readability.

Plastic with personality: Increasing student engagement with manikins

BACKGROUND

Simulation allows students to practice key psychomotor skills and gain technical proficiency, fostering the development of clinical reasoning and student confidence in a low risk environment. Manikins are a valuable learning tool; yet there is a distinct lack of empirical research investigating how to enhance engagement between nursing students and manikins.

OBJECTIVE

To describe student perspectives of a layered, technology enhanced approach to improve the simulation learning experience.

EDUCATIONAL FRAMEWORK

Tanner's Model of Clinical Judgment underpins the entire curriculum. This study additionally drew on the principles of narrative pedagogy.

INTERVENTION

Across ten teaching weeks, five separate case studies were introduced to students through short vignettes. Students viewed the vignettes prior to their laboratory class. In the labs, manikins were dressed in the props used in the vignettes.

SETTING

The innovation was trialed in a second year core subject of a Bachelor of Nursing program in a large urban university in the autumn semester of 2014.

DATA COLLECTION AND ANALYSIS

Following ethics approval, students were emailed a participant information sheet. A focus group of nine students was held. The discussion was digitally recorded and transcribed verbatim prior to being subject to thematic analysis. Students' comments (143) about the vignettes in their standard subject specific student feedback surveys were also considered as data.

RESULTS

Four themes were identified: Getting past the plastic; knowing what to say; connecting and caring; and, embracing diversity. The feedback indicated that these measures increased students ability to suspend disbelief, feel connected to, and approach the manikins in a more understanding and empathetic fashion.

CONCLUSIONS

In addition to achieving increased engagement with manikins, other advantages such as students reflecting on their own values and pre-conceived notions of people from diverse backgrounds were realized.

Small group learning: Graduate health students' views of challenges and benefits

Abstract Background: For health-care professionals, particularly nurses, the need to work productively and efficiently in small groups is a crucial skill required to meet the challenges of the contemporary health-care environment. Small group work is an educational technique that is used extensively in nurse education. The advantage of group work includes facilitation of deep, active and collaborative learning. However, small group work can be problematic and present challenges for students. Many of the challenges occur because group work necessitates the coming together of collections of individuals, each with their own personalities and sets of experiences.

AIM

This study aimed to identify challenges and benefits associated with small group work and to explore options for retaining the positive aspects of group work while reducing or eliminating the aspects the students experienced as negative.

METHOD

Online survey; thematic analysis.

RESULTS

Over all, students experienced a range of challenges that necessitated the development of problem-solving strategies. However, they were able to elucidate some enjoyable and positive aspects of group work. Implications for teaching and learning are drawn from this study.

CONCLUSION

The ability to work effectively in small groups and teams is essential for all health-care workers in the contemporary health environment. Findings of this study highlight the need for educators to explore novel and effective ways in which to engage nurses in group work.

Small group learning: graduate health students' views of challenges and benefits

Abstract Background: For health care professionals, particularly nurses, the need to work productively and efficiently in small groups is a crucial skill required to meet the challenges of the contemporary health-care environment. Small group work is an educational technique that is used extensively in nurse education. The advantage of group work includes facilitation of deep, active and collaborative learning. However, small group work can be problematic and present challenges for students. Many of the challenges occur because group work necessitates the coming together of collections of individuals, each with their own personalities and sets of experiences. Aim: This study aimed to identify challenges and benefits associated with small group work and to explore options for retaining the positive aspects of group work while reducing or eliminating the aspects the students experienced as negative. Method: Online survey; thematic analysis. Results: Over all, students experienced a range of challenges that necessitated the development of problem-solving strategies. However, they were able to elucidate some enjoyable and positive aspects of group work. Implications for teaching and learning are drawn from this study. Conclusion: The ability to work effectively in small groups and teams is essential for all health care workers in the contemporary health environment. Findings of this study highlight the need for educators to explore novel and effective ways in which to engage nurses in group work.

District nurse role in end-stage COPD: a review

District Nurses (DNs) are core providers of end-stage care in the community but appear to have little contact with patients suffering from non-malignant diseases, such as chronic obstructive pulmonary disease (COPD). This review found limited literature describing the role of DNs in end-stage COPD care, and the studies that did touch on the subject restricted their discourse to the frequency of interaction. A clear bias of end-of-life services to patients with malignancy was noted, as well as a call for community services to extend care to all end-stage patients regardless of underlying disease. In addition, there was a further call for DNs to apply a more holistic approach to care, as described in the literature. Finally, it was clear that while ongoing community intervention is necessary for end-stage COPD patients, support and training is essential to equip DNs to care for these vulnerable patients.

Screening for pain in patients with cognitive and communication difficulties: evaluation of the SPIN-screen

ABSTRACT - The scale of pain intensity (SPIN)-screen is a simple visual tool for the screening and measurement of pain intensity, which is designed to be accessible by patients with cognitive and communication problems. It was applied prospectively in a consecutive cohort of 79 patients admitted to a tertiary specialist neurorehabilitation unit, of which 86% had significant cognitive/communicative disabilities. In all, 71 patients (90%) responded to the SPIN. Concurrent validation against a standard numbered graphic rating scale (NGRS) showed a strong overall correlation (rho 0.94 p < 0.0001). When the NGRS was converted to an equivalent six-point scale, weighted Kappa tests demonstrated 'almost perfect' agreement (K = 0.81, SE 0.083) between the two sets of ratings. Repeat testing after 24 hours provided preliminary evidence for the stability and responsiveness of the SPIN-screen, but these require further evaluation. Of those who expressed a preference for one tool over the other, 70% preferred the SPIN. The study provides support for application of the SPIN-screen as a routine screening tool in this group of patients.

The Rehabilitation Complexity Scale: a simple, practical tool to identify 'complex specialised' services in neurological rehabilitation

New commissioning arrangements in the NHS require the identification of 'complex specialised' (CS) services, as distinct from more 'general' or 'district specialist' (DS) rehabilitation services, to determine differential cost-tariffs. In this cross-sectional postal survey representing 49 inpatient neurological rehabilitation services in the UK, no clear service characteristics that distinguished CS services (n = 20) from DS services (n = 29) could be identified. On the other hand, the Rehabilitation Complexity Scale (RCS) demonstrated clear differences between the two types of service, in terms of the complexity of case mix and of the rehabilitation inputs provided. District specialist services reported a median RCS score of 7 (interquartile range (IQR) 6-8), whereas CS services reported higher scores (median 9 (IQR 7-11)) (Mann-Whitney z = -9.3, p < 0.0001). Carrying a caseload in which 50% of patients had total RCS scores > or = 9 appeared to be a sensitive and specific indicator of a CS service. This study represents the first reported use of the RCS. Feedback regarding the utility of the tool was generally favourable, although other more detailed instruments are likely to be required to distinguish complexity at the very top end of the scale. As NHS services tackle the challenges posed by Payment by Results for management of patients with complex needs, it is suggested that this approach may have application in other fields of clinical practice.