Junior doctors’ experience of interprofessional shadowing in a palliative care setting

ABSTRACT

Interprofessional shadowing, whereby medical students take on the role of another profession, is an effective interprofessional education (IPE) method to promote interprofessional teamwork. Palliative care is an ideal setting for IPE as multidisciplinary teams work together to deliver holistic patient care. This brief report explores junior doctors’ experiences in shadowing nurses to provide care to patients in a hospice setting in New Zealand. We conducted semi-structured interviews with six participants to find out the impact that this shadowing experience had on their professional development and feasibility of incorporating this activity into the undergraduate medical curriculum. Inductive thematic analysis revealed that shadowing a nurse for two days increased participants’ awareness of the nursing role and gave them the opportunity to develop a personal relationship with their patients, both of which made participants actively reflect on the value of IPE and the way they practice medicine. Participants considered the palliative care setting as conducive to IPE and saw the value of incorporating interprofessional shadowing into the undergraduate medical curriculum.     

Making them more vulnerable: nursing insights on the irony of using questionnaires

TOPIC: Nursing insights on the experience of using standardized questionnaires during hospice care. PURPOSE: To explore and describe the experience of hospice staff using questionnaires on hospice clients: whether such instruments help or hinder the holistic, compassionate hospice practice and to set this topic on the research agenda in the hope of generating critical reflection on this important aspect of hospice care. SOURCES: A cross-section of hospice staff interviewed about their experience with administering the questionnaires. (Findings from research conducted with hospice clients on their experience of questionnaires are published separately.) CONCLUSIONS: The initial findings indicate that staff perceive questionnaires as negatively impacting on their efforts to engage in holistic and compassionate hospice practice and point to a major irony that questionnaires, designed for the supportive care of the vulnerable, actually make the vulnerable more vulnerable.     

Staff stress in the children's hospice: causes,effects and coping strategies

Although there are an increasing number of hospices opening around the country, the concept of the children's hospice is still relatively new. Although stress involved in giving palliative care to adults has been examined quite extensively, very little work has been done on the impact of caring for children in the hospice setting. This article is a literature review, examining the causes and effects of staff stress in the children's hospice, as well as the factors that enable staff to cope with working in this environment. It concludes that the main causes of stress are often related to conflicts within the staff group, communication problems and role conflict. Poor relationships with the child's family as well as the inability to relieve distressing symptoms the child may be experiencing have also been identified as common sources of stress. Teamwork, good communication and the home-like atmosphere of the hospice all contribute to enabling staff to deal with work stress. Staff support groups may be beneficial, but need to be run well, by someone experienced in leading such groups. Additionally, stress can be reduced by providing staff with the appropriate training and education and by encouraging them to take some responsibility for preventing and relieving stress themselves.     

Aggressive End-of-Life Care Significantly Influenced Propensity for Hospice Enrollment Within the Last Three Days of Life for Taiwanese Cancer Decedents

ContextLate hospice enrollment exacts a substantial toll from patients, families, hospices, and society. The relationship between the propensity for late hospice enrollment and aggressive health services received at the end of life (EOL) has been underinvestigated.ObjectivesTo identify determinants of hospice enrollment within the last three days of life.MethodsRetrospective population-based cohort study using administrative data for 31,529 Taiwanese cancer decedents who used hospice care in their last year of life.ResultsRates of hospice enrollment within the last three days of life (16.80%–18.73%) remained constant over 2001–2006. After adjustment for patient demographics and disease characteristics, physician specialty, availability of health care resources at the hospital and regional levels, and historical trends, late hospice enrollment was more likely if Taiwanese cancer patients received chemotherapy, had multiple emergency room visits or hospital admissions, and used the intensive care unit in their last month of life (adjusted odds ratio [95% confidence interval] (AOR [95% CI]): 1.61 [1.44–1.80], 1.40 [1.29–1.52], 1.78 [1.51–2.09], and 1.45 [1.19–1.76], respectively). Late hospice enrollment was less likely for patients with hospital stays >14 days or who received cardiopulmonary resuscitation in their last month of life (AOR [95% CI]: 0.51 [0.45–0.58] and 0.41 [0.25–0.65], respectively).ConclusionAggressive EOL care played a more significant role than patient, physician, or hospital characteristics in determining the propensity of Taiwanese cancer patients to be enrolled in hospice care within their last three days of life. Clinical and health policies should aim to avoid aggressive care when it will not benefit patients but may preclude timely hospice enrollment.     

Person centred nursing care in radiation oncology: A case study

PurposeThe aim of this case study is to describe clinical staff perceptions of implementing a person-centred model of nursing in an outpatient radiotherapy treatment department, using a Primary Nursing/Collaborative Practice framework. The questions are: 1) what are the nursing and radiotherapy staff perspectives of the changed model of care, 2) what factors impacted on aspects of the evolving model?, and 3) how was interdisciplinary collaboration influenced by the new model?MethodsAn instrumental case study addressed the multiple perspectives of several radiotherapy health professionals, within a qualitative approach, to assess the new model of nursing care. Interview data were obtained from thirteen clinical staff over a six month period approximately one year after the model was implemented.ResultsThe new model supports nurses to work more closely with the individual patient, with some perceived positive patient outcomes. Nurses reported increased satisfaction with their work, more autonomy and responsibility, and improved working relationships with medical staff. They also became more aware of the holistic approach to support positive patient outcomes. However, this study acknowledged that education was required for nurses to provide holistic care, especially in the context of complex interdisciplinary relationships.ConclusionsA person-centred nursing approach in radiotherapy represents a radical change to the functional approach, providing some benefits for patients. However, the challenges of providing holistic care in the context of complex interdisciplinary relationships are evident, and this study acknowledges the importance of a team approach to addressing changes in practice in the future.     

How home hospice care facilitates patient and family engagement

Little is known about how patient and family engagement manifests in home hospice care. This qualitative study included interviews and observation of home hospice care with 18 patients, 11 caregivers, and 26 hospice workers in the United States. Structural factors (e.g., home setting, ample time, personal relationships), hospice worker strategies (e.g., patient education and presenting choices), and family member support facilitated engagement. Barriers to engagement included difficult relationships and unavailable or unwilling family members. Home hospice care demonstrates potential strategies for continuous, informed, and holistic engagement. These engagement strategies may translate to other arenas of health care.     

A programme of individualized and self-administration of medicines in a hospice

Hospice care is changing. Statistics show that people are surviving longer with cancer and many more are choosing to be cared for in the community. The hospice is no longer an institution solely for the care of people in the terminal phase of their illness but is involved in the palliation of symptoms, so allowing patients to return home to independent living. It was with this in mind that we recognized the need for the introduction of a programme of individualized and self-administration of medication at the hospice where we work. Although self-administration of medication was our first aim, the individuality of care brought about by its introduction, the adaptations required to include all palliative care patients and the resulting enhancement of holistic patient care, has become the main thrust of the project. This article will explore the term 'self-administration of medication'; the evidence of its use in other areas of health care; the rationale for change within the hospice movement; consequences to practice; and the staged implementation of a programme of individualized and self-administration of medication.     

In search of models of care

Abstract

Most hospice programs list “spiritual support” among the characteristics of hospice care, but then avoid defining it except in ambiguous ways. The author argues that without careful definition of “spiritual,” hospice care will be little different in quality from that offered in acute and chronic care centers. The “spiritual quest” is defined as a unifying and integrating process that permits a human being to be oriented to wholeness or dignity. Also discussed is the challenge to hospice care staff to defy trends in recent health care that allow staff rather than patients to determine what dignity means, thereby making the patient an object rather than a subject.     

Providing Palliative and Hospice Care to Children,Adolescents and Young Adults with Cancer

ObjectivesTo describe palliative, concurrent, and hospice care in pediatric oncology in the United States (US), we present a clinical scenario illustrating palliative and hospice care, including eligibility for concurrent care, insurance coverage and billing, barriers to accessing quality pediatric palliative and hospice care, and implications for oncology nursing practice.Data SourcesPeer-reviewed articles, clinical practice guidelines, professional organizations, and expert clinical opinion examining pediatric oncology, palliative care, and hospice care.ConclusionUnderstanding the goals of palliative and hospice care and the differences between them is important in providing holistic, goal-directed care.Implications for Nursing PracticeOncology nurses play a pivotal role in supporting the goals of pediatric palliative care and hospice care and in educating patients and their families. Nurses form trusting relationships with pediatric oncology patients and their families and are in a position to advocate for best palliative care practices as disease progresses to end of life, including when appropriate concurrent care or hospice.     

Development of a care pathway for babies being discharged from a level 3 neonatal intensive care unit to a community setting for end-of-life care

The development of a care pathway for babies being discharged from a level 3 neonatal intensive care unit (NICU) to a community setting for end-of-life care is discussed. The development of the care pathway was a collaborative project between a level 3 NICU, the local children's hospice and the local primary care trust. The development of the care pathway enables parents to decide where they want their babies to be cared for: NICU, hospice or home care. It enables staff to rapidly refer babies and their families to hospice or community care and provides staff with the support they also need during this difficult time.     

Hospice care in Calgary: Survey of family physicians on their knowledge,experience, and attitudes

ObjectiveTo explore Calgary family physicians’ knowledge about hospices, their attitudes toward the referral process, and their understanding of barriers to referral for hospice care.DesignSurveys were mailed to 400 randomly selected participants. The survey contained 18 questions related to hospice care, physician experience, attitudes, and perceived barriers to making a hospice referral.SettingCalgary, Alta.ParticipantsFamily physicians.ResultsIn total, 104 surveys were mailed back. Family physicians agreed that palliative care in a hospice setting can greatly improve quality of life for patients, but only 2 of 6 knowledge questions about hospice care were answered correctly by most. Family physicians with special areas of interest or subspecialties were more likely to feel well-informed about hospice referrals (P = .017), indicated a higher comfort level discussing hospice and palliative care (P = .030), and were less likely to defer discussing it with patients (P = .023). Physicians with a special interest in palliative medicine were more likely to correctly answer the knowledge questions (P < .034) and to be familiar with the referral process (P < .001), patient eligibility (P < .001), and the palliative home care program (P = .003). Qualitative analysis revealed support for palliative home care and consultation services but concerns about caregiver coping and family issues. Concerns about disengagement of family physicians and uncertainty about the referral process are obstacles to referral.ConclusionWhile Calgary family physicians are appreciative of hospice care, there are knowledge gaps. It is important to engage family physicians in the referral process.     

Ritual: the final expression of care

Hospice nurses know that all their patients will die. There are several potential benefits of including rituals and healing practices into the hospice care setting for staff. Evidence suggests that not only does it provide an outlet for hospice workers to express their grief and reflect on their work in an accepting environment; providing closure for their patient's passing but it has also been shown to decrease the risk of burnout and compassion fatigue. This article discusses the important aspects of grief rituals and provides an illustrative example of one such ritual.     

Development of a holistic admission assessment: an integrated care pathway for the hospice setting

This article describes the development of a holistic admission assessment for all inpatients admitted to a 66-bedded hospice, structured in the form of an integrated care pathway (ICP). The need for an improved assessment process was identified by clinical staff, who recognized that the existing assessment was not truly holistic and was dependent on the skills of the assessors. The assessment also lacked appropriate goals and actions. The recently published National Institute for Clinical Excellence (NICE) guidance on Improving Supportive and Palliative Care for Adults with Cancer, has also highlighted key areas for the improvement of patient assessment in specialist palliative care (NICE, 2004). Implementation of the ICP has resulted in a systematic and timely holistic assessment process for patients. The ICP addresses effectively the NICE recommendations for the assessment of specialist palliative care patients.     

Goal setting as a measure of outcome in palliative care

Setting goals and assessing outcomes are essential elements in palliative care. This paper describes a multiprofessional project, conducted under the auspices of clinical audit, which attempted to evaluate important outcomes of care. Over a six-month period there were 123 consecutive admissions to the hospice. These patients and their carers, as well as the staff, were encouraged to set explicit goals for, and evaluate outcomes of, their care. As anticipated, we encountered many difficulties in this, but there were benefits. We were able to record goals of admission from the patient in 97 cases (79%), their main carer in 74 cases (63%) and from hospice staff in 120 cases (98%). Patient and carer goals were often more functional and specific whereas the staff goals tended to be more problem or symptom focused. The achievement of these goals was evaluated by patients, carers and staff at discharge or death (where possible) with the majority being fully or partially met. Only 15 patients and 9 carers thought that some or all of their goals had not been achieved with just 4 recording that their goals had changed. Overall, it was a worthwhile (although time-consuming) exercise and, as a result of the 'audit', clear goals and outcomes from patient, carer and staff perspectives are now routinely recorded for all admissions to the hospice and are used to focus multiprofessional patient review. Having analysed the process as well as the results of the 'audit', we would encourage others not to be daunted from undertaking similar projects.     

Providing pediatric palliative care through a pediatric supportive care team

We expect children to live to adulthood; however, children do die. Some die from diseases they are born with, others from accidents or illnesses. The devastating effects associated with the death of a child can be lessened by providing palliative, hospice, and bereavement care. At St. John Hospital (SJH) in Detroit, MI, the services that provide care for children chartered the Pediatric Palliative Care Committee. The committee brought together staff from the inpatient pediatric unit, cancer center, home care, and hospice care services within the St. John Health System. Utilizing established staff and services, this group began to provide care for children with potentially life limiting illnesses in a coordinated, multidisciplinary team approach. The positive outcomes of this approach include an overall increase in patient and family satisfaction with care, a decrease in the number of emergency room visits and inpatient hospital stays, and an increase in patient and family informed decision making and goal setting. Positive outcomes for the staff include support in caring for children with life limiting illnesses and an increase in satisfaction with the care they provide.     

Posthumous reproduction and palliative care

Posthumous reproduction is an issue fraught with legal, ethical, religious, and moral debate. The involvement of the hospice and palliative care community in this debate may be peripheral due to the fact that other health care professionals would be actually delivering the services. However, the hospice and palliative care community are more likely to treat patients considering posthumous reproduction as they near the end of their lives. This article provides the hospice and palliative care community with a review of the medical, ethical, and legal considerations associated with posthumous reproduction. Having knowledge of these issues, and a list of available resources, will be useful if hospice and palliative care staff find themselves facing a patient or family that is considering posthumous reproduction.