Impact of a hospital palliative care service: perspective of the hospital staff

The first New Zealand hospital palliative care support service was established in 1985. Different service models have now been adopted by various major hospitals. In 1998, a palliative care service, funded by Mary Potter Hospice, was piloted at Wellington Public Hospital. Twelve months post-implementation, the hospital staff's views of the service were evaluated. It was found that referrals to palliative care from hospital specialities outside the Cancer Centre increased. While most doctors, nurses and social workers strongly agreed or agreed that the service positively influenced patients' care and effectively addressed their symptom management needs, spiritual needs were less often met. Over 90 percent of each discipline strongly agreed or agreed that the service had assisted them in caring for patients, but, only about a half agreed that useful discharge planning advice and staff support was provided. Significant differences in responses were found between different disciplines and specialities. One fifth of the staff identified palliative care education needs. Recommendations are made concerning the development of a future hospital palliative care service.     

Changing practice: use of audit to change oral care practice

Although oral problems are common in palliative care, oral care can be a neglected area of practice. This article discusses the introduction of an oral care protocol and standard in one palliative care unit. The project used audit tools developed by Lee et al (2001) and involved a survey of the oral care knowledge of nursing and medical staff, and a retrospective survey of current practice using 50 sets of patients' notes. A standard and documentation were developed with the aim of ensuring oral care was both consistent and in line with best practice. Training was provided to all staff within the unit. Three months later oral care practice was audited. The results suggested improvement in all aspects of oral care practice. Dissemination of oral care documentation and training across the trust is underway. This article describes the processes used, highlighting the importance of assessment in oral care and the need for teamwork in rolling out changes both within and beyond a single unit.     

An audit of pressure ulcer incidence in a palliative care setting

This article reports a continuous audit of pressure ulcer incidence within a specialist palliative care unit over 2 years. Details of every patient admission were considered (542 patients). Of these, 26.1% were admitted with pressure ulcers while 12.0% developed pressure damage during their stay. The retrospective audit looked at the ulcers developing in the unit and found these patients were older, stayed 12 days longer and more of them died than the average for all patients admitted to the unit. In total, 95.3% were accurately assessed at 'high' or 'very high' risk using the Waterlow (1985) Pressure Sore Risk Assessment Tool and 89.2% of ulcers were Grade 1 or 2 measured using the Stirling Pressure Sore Severity Scale (Reid and Morrison, 1994). Of all developing ulcers, 78.4% were sacral and the position of the tumour, as well as comfort and positioning difficulties were considered most often responsible. Despite this knowledge and many 'improvements' introduced, the incidence did not improve with superficial ulcers often developing in the last days of life.     

Safeguarding children: audit of staff knowledge

Following the publication in 2006 of 'Working together to safeguard children' (HM Government 2006), an audit was undertaken to assess the working knowledge of children's services staff about safeguarding. The aims of the audit were to: identify knowledge of key legal issues required when caring for children and young people; highlight gaps in knowledge; identify training needs. Staff in acute children's services in two district general hospitals and in the child and adolescent mental health service were interviewed using a structured questionnaire. The results of the audit showed that professional's knowledge about the sharing of information was good. This may have been due to a recent introduction of a policy on sharing information and also mandatory training on safeguarding children, which includes issues regarding sharing information. However, the audit identified a lack of understanding about parental responsibility with only 41 per cent of staff able to provide an acceptable response. Other gaps in staff knowledge were identified concerning legal orders, particularly emergency protection orders and police protection powers.     

An audit of the use of the Barthel Index in palliative care

The Barthel Index (Mahoney and Barthel, 1965) is an objective tool which assesses an individual's ability to perform activities of daily living; for example, personal care, mobility, transfers, bathing and feeding. The purpose of this study was to investigate whether the Index could be used with patients with life-threatening illnesses who are admitted to the inpatient intermediate care unit, to aid clinical practice, establish patients' current level of function, and highlight any progress or deterioration in abilities. The overall aim was to facilitate discharge planning and ensure that patients were managed in their preferred place of care. This was a clearly defined group of patients in a specific clinical area. The authors recognise that to improve consistency of findings, the study may need to be applied to a larger cohort of patients with a greater research emphasis. The article presents the results of an audit of 50 patients. The findings suggest that those patients with a low Barthel score on admission, or those with a score dropping by ten or more per week, are significant predictors of a short prognosis. It concludes that the Barthel Index would be a useful tool in the community to prevent inappropriate admission for those with a low score where the patient wishes to die at home. It could also be used as a monitoring tool to help discharge planning and fast-tracking to the preferred place of care in inpatient settings, and may also assist in community health care (CHC) planning.     

An audit of long-stay patients in an inner city palliative care centre

An audit was carried out of patients with long admissions to a palliative care centre in central London. The records of patients remaining in the centre for more than 28 days were examined to see whether there were particular features characteristic of long-stay patients which could be identified to improve future admission planning.     

Improving district nurses' confidence and knowledge in the principles and practice of palliative care

Title.  Improving district nurses' confidence and knowledge in the principles and practice of palliative care.
Aim.  This paper is a report of part of an evaluation of the impact of a national palliative care education and support programme on the knowledge and confidence of members of district nursing teams.
Background.  District nursing teams are the mainstay of 'hands on' provision of care at home. In recognition of their central role, the English Department of Health commissioned a national palliative care education programme as postregistration education had been limited.
Methods.  The evaluation, conducted between 2002 and 2004, had a mixed methods design. In the summative component, 1280 nurses were randomly selected from eight cancer networks to receive postal questionnaires 1 year apart, before and after the educational intervention. Changes in scores were calculated and a multiple regression analysis undertaken to identify predictors of improvement in confidence in competence and knowledge. The formative component involved qualitative interviews with a sub-sample of 39 district nurses participating in the programme.
Findings.  Nurses who responded in both years (374/32%) were included in the analysis. There was a small statistically significant increase in confidence in palliative care competency and knowledge after participation in the educational programmes. Nurses without district nursing qualifications and who had never worked in specialist palliative care had the largest improvements in scores. Qualitative data supported these findings.
Conclusion.  The findings suggest that the education programme led to improvements in self-reported district nursing confidence in palliative care competencies and knowledge; it is likely that the baseline level of palliative care confidence in competency and knowledge has as a result been raised nationally.     

Enhancing hospital nurses' knowledge of palliative care: a network nurse programme

The palliative care network nurse programme was developed to educate and skill generalist nurses in the care of the dying patient within the acute hospital setting. It developed at the request of nurses who had been involved in the piloting of the Liverpool Care of the Dying Pathway. The programme consists of a monthly meeting that encompasses an educative component and networking opportunities. In a preliminary evaluation of the programme, a questionnaire was sent to the network nurses (response rate 80%, n = 33). The nurses reported the programme to be beneficial in providing them with increased palliative care knowledge. Support and networking opportunities were also identified. This article discusses the programme, the evaluation findings and makes suggestions for further research.     

Graduating nurses' self-efficacy in palliative care practice: An exploratory study

BackgroundEducational institutions and the health care industry agree that graduates from professional programs need to be “work ready” and capable of delivering competent and confident nursing care. One measure of program success is the student's self-efficacy in meeting expected graduate capabilities. In this study student's self-efficacy is related to palliative care graduate capabilities.AimTo explore graduating Bachelor of Nursing Science (BNSc) students' self-efficacy in caring for palliative care patients.DesignA qualitative design using semi-structured face-to-face interviews.SettingA regional Australian university.ParticipantsA purposive sample of 10 students in their final semester of study in a Bachelor of Nursing Science degree program.MethodSemi-structured face-to-face interviews were conducted. Interview questions were informed by published palliative care graduate capabilities. Interview data were transcribed verbatim and coded by capability. The coded data were then analysed to determine evidence of self-efficacy in caring for palliative care patients.ResultsAll participants had experiences in caring for palliative care patients. However, the responses did not consistently reflect high degrees of self-efficacy in four documented palliative care graduate capabilities required to care for persons with a life-limiting illness.ConclusionsThe findings support others that have identified gaps between curriculum and health care industry requirements in terms of students' beliefs about their empowerment to deliver nursing care as graduates. Education interventions and approaches to program evaluation require further development to better support students' growth of self-efficacy in undertaking their graduate roles.     

Indigenous ethnic minorities and palliative care: exploring the views of Irish Travellers and palliative care staff

Indigenous people are among the ethnic minorities who encounter palliative care services. This research shows that Irish Travellers have little experience of specialist palliative care and that specialist palliative care providers have little knowledge or experience of Irish Travellers. Characteristics of Irish Travellers culture including the importance of hope, avoidance of open acknowledgment of death, the importance of family and the avoidance of the place of death (including moving away or burning caravans where death has occurred) challenge the provision of specialist palliative care. Individualisation of patient care, a feature of specialist palliative care can help staff provide appropriate care.     

Rehabilitation hospital staff knowledge and attitudes regarding pain

No published studies exist that document pain-related knowledge, attitudes, or educational needs of clinical staff in a rehabilitation hospital; the purpose of this study was to obtain such information to aid in the development of an institutional pain care improvement project. A survey regarding knowledge and attitudes about pain and perceived areas of educational need was administered to all staff with inpatient care responsibilities. Results show that rehabilitation hospital staff hold generally progressive attitudes toward the treatment of pain but with a substantial degree of ambivalence about the use of opioids in the treatment of pain. Staff rate their own lack of education about pain management as one of the chief barriers to effective pain management, and a large percentage report feeling uncomfortable with various technical aspects of pain care. We discuss the implications of this survey for understanding and improving pain care in rehabilitation settings.     

An audit into the effects of aromatherapy massage and the cancer patient in palliative and terminal care

Aromatherapy massage has now become more widely known. An audit was conducted to assess the physical and psychological effects of aromatherapy and the cancer patient in palliative care. The audit was difficult to evaluate, but did achieve an 80% success rate in that almost all the patients treated did derive benefit in some way. It could be debated, however, whether benefit was derived from (a) the patient being given individual attention for a period of time; (b) talking to that person; (c) use of touch and massage and (d) use of aromatherapy oils. To answer these questions, a further more fully controlled study would need to be carried out.     

Optimising palliative and end of life care in hospital

The acute hospital setting is increasingly regarded as an important area for the delivery of palliative care. A significant number of patients with advanced, life-limiting illness have a range of palliative care needs, some of which can be met by ward staff, but others may require additional, specialist input. Several factors have the potential to limit the palliative care patients in hospital receive, not least of these being disagreement about when and how the transition to palliative care should take place. In practice, however, palliative care can readily be delivered in conjunction with active disease management.     

Implementing audit in palliative care: an action research approach

AIM: To investigate the factors that influence the successful implementation of audit in a palliative care setting. BACKGROUND: Quality assurance is a necessary component of contemporary health care. In the past, palliative care has not generally been subject to systems of audit and quality management. However in recent years the need for all health care organizations to have clear policies and procedures for maintaining quality has become more pressing. METHOD: An action research project was conducted to investigate the implementation of audit in a palliative care setting, which involved the application and modification of the Support Team Assessment Scale (STAS). FINDINGS: A collaborative approach was adopted and this facilitated the identification of factors vital to successful introduction of the audit methodology into the unit. These included effective teamwork, the input of an external facilitator, good relationships with management and prompt and relevant feedback on progress. The use of STAS was fully integrated into the work of the unit and a robust programme of audit has been established. CONCLUSIONS: Combining the cyclical nature of action research methodology and the audit process with Lewin's change theory provided a clear conceptual framework for the research. This approach would be applicable in a range of health care settings to bring about improvements in quality management.     

Reflections on clinical audit in palliative care following an attempt to audit urinary catheterization

Audit has a high profile within palliative care quality initiatives. However, there are numerous potential pitfalls to auditing. We had hoped to perform a multicentred multiprofessional audit on urinary catheterization of hospice patients. Unexpectedly, the problems encountered highlighted numerous flaws in our approach to audit. An initial standard-setting pilot study, using a prospective observational methodology, generated results for 25 patients. The audit cycle was not pursued, as the data and the process did not appear valid. Conversely there were valuable lessons from reflecting on our mistakes and reviewing historical 'wisdom'. For example, audit's interface with research can easily be misunderstood and the difficulties of audit in palliative care can be underestimated. Particularly concerning was the potential for harm from insufficient rigour within audit processes, in allowing invalid data to influence practice. Conversely, despite risks, robust studies within audit may inform the limited palliative care research base.