Hospice program integration: An issue for policymakers

As the number of hospice programs in the United States expands, policymakers face a variety of issues concerning the care of the terminally ill. Do hospice programs offer a truly unique approach in caring for the dying? Are hospice services cost effective? Should hospice programs become integrated into the mainstream of medical care service delivery? Based on data from hospice programs in an industrialized Midwestern state, this paper explores the strategies employed by hospice programs to become integrated, the conflicts that have arisen among providers of hospice care, and the impact of hospice program integration on patient care.

Results show that as hospice programs become more integrated, they have lost some of the idealism on which they were founded, have altered organizational structures, and have changed certain patient services. However, there is no evidence to suggest that integration of hospice programs into the medical mainstream has decreased the quality of patient care or patient satisfaction for hospice services.     

The Supportive Hospice and Aged Residential Exchange (SHARE) programme in New Zealand

Research indicates that staff in aged residential care may be unprepared for their role in palliative care provision. In collaboration with a local hospice, the project piloted an innovative problem-based experiential learning intervention Supportive Hospice and Aged Residential Exchange (SHARE) to enhance aged residential care staff palliative care skills. The aim was to explore the impact of SHARE for staff. SHARE was implemented in two aged residential care facilities in one urban centre for six months. Measurement of the impact of the intervention consisted of 1) pre-test-post-test questionnaires (n = 27) to assess changes in staff confidence in palliative care delivery 2) Eleven post-intervention interviews to describe staff perceptions of SHARE. Results from the SHARE pilot indicate that the intervention overall is seen as a success, especially in relation to advanced care planning documentation. Relationships between hospice and facility staff, and consequently facility staff and residents are seen as the key to the success of the project. Staff survey results indicated increased confidence in palliative care delivery and decreased depression. Key lessons learnt from for the development of any palliative care intervention within aged residential care include the importance of reciprocal learning, as well as the necessity of a strong partnership with key stakeholders.     

Hospice nursing: the specialty

The purpose of this study was to identify and delineate what experienced hospice nurses perceive as the knowledge and skills base essential to their practice of hospice nursing as a specialty. Little of this specialty is taught in basic nursing programs, so another purpose was to determine the methods hospice nurses use for knowledge and skills acquisition. The qualitative study method of focused ethnography was used. This method allowed the researcher to examine hospice nurses in the context of their own community-based agency, enter the research arena with specific questions, describe the topic from the viewpoint of the participants, use multiple data sources, and begin data analysis concurrently with data collection, which continued until saturation was reached. During data analysis, 11 categories emerged. Four of these categories involved skills: (a) assessment skills, (b) communication skills, (c) technical skills, and (d) management skills; and seven categories primarily involved knowledge: (a) end-stage disease process, (b) signs of impending death, (c) palliative therapeutics, (d) collaboration between disciplines, (e) advocacy, (f) philosophy and ethics of hospice care, and (g) family dynamics. Of these 11 categories, the one discussed and observed most often was that of assessment skills. It was found that the hospice nurses learned their specialty by doing it. However, the need for graduate education in hospice nursing became apparent.     

Autonomy,privacy and informed consent 2: postnatal perspective

The nursing and healthcare ethics literature over the past 10 years has focused on issues of patient autonomy and patient rights. Despite the growing volume of literature exploring such topics, there is little empirical work investigating what is actually happening in clinical nursing or midwifery practice in relation to patient autonomy, privacy or informed consent, from the perspective of either patients or staff. This four-part series reports the results of a Scottish study that formed part of a multisite comparative research project funded by the European Commission, investigating issues of patient autonomy, privacy and informed consent. This article, the second of four, explores the issues of autonomy, privacy and informed consent in maternity care. The research questions asked were: (1) What is the perception of mothers' autonomy, privacy and informed consent in Scottish NHS hospitals, from the point of view of both mothers and midwives? (2) Are there differences in the perceptions of mothers and midwives on these issues? Data were collected by a self-completion questionnaire for mothers (n = 243) and staff (n = 170) on postnatal units in both district general and university teaching hospital. Results indicated that there are differences between the perceptions of mothers and midwives in relation to mothers' autonomy, privacy and informed consent. Most differences were found in the information-giving and decision-making elements of autonomy.     

Inclusive early childhood education and care: a longitudinal study into the growth of interprofessional collaboration

ABSTRACT

Inclusive early childhood education and care (ECEC) requires interprofessional collaboration between professionals with diverse professional backgrounds. Following developments in human services, there is a growing interest in the role of interprofessional teams in community-based settings for young children. In a three-year longitudinal study, we investigated interprofessional collaboration (IPC) between staff from childcare, education and youth care. At the individual level, a survey was used for the analysis of IPC competences. At the network level, we investigated professional relationships between individuals using social network analysis. Results of a multilevel mixed linear model showed an increase in interdependence and reflection on process of individual staff, followed by the progressive development of perceived team performance. Smaller networks with higher density and professionals’ centrality predicted more positive perceptions of inclusive ECEC. We discuss our findings in the context of growing interest in interprofessional teams in ECEC.     

Palliative day care: a qualitative study of service users' experiences in the United Kingdom

In many countries, specialist palliative day care for patients with life-limiting conditions is provided by specific teams of professionals from a range of relevant disciplines. During 2006 to 2007, the day care services at a hospice in the U.K. were redesigned so that specialist palliative care sessions replaced the existing long-established, traditional day care model. The purpose of this study was to enhance the understanding of those aspects of the service that the users valued most (the "X-factor"). Qualitative data were collected via semistructured interviews with 29 patients and eight carers. These data were subjected to a framework analysis. The users of the service used poignant and powerful words to describe the special qualities that they valued, some phrasing it as the X-factor. The data are presented under three themes: the quality of the staff; the sense of community; and relationships. Of these, the relationships between and within the staff and patient groups held the greatest significance for the patients. Service providers need to recognize that opportunities for the formation of relationships between the patients, staff, and carers are of utmost importance when designing palliative day care services.     

Hospice experience and perceptions in nursing homes

The purpose of this study was to describe the experiences and perceptions of hospice nurses caring for residents in long-term care facilities. The study used a fax-back survey to gather data from 69 hospice nursing and nurse managers in 24 hospices across one Midwestern state. Respondents reported negative experiences with pain management and care coordination in the nursing home setting. Although hospice is thought to be a benefit to residents, hospice staff report frustration in caring for nursing home patients, especially in trying to control pain. The study identifies opportunities for improvement in hospice and nursing home staff relationships.     

Dignity,Death, and Dilemmas: A Study of Washington Hospices and Physician-Assisted Death

The legalization of physician-assisted death in states such as Washington and Oregon has presented defining ethical issues for hospice programs because up to 90% of terminally ill patients who use the state-regulated procedure to end their lives are enrolled in hospice care. The authors recently partnered with the Washington State Hospice and Palliative Care Organization to examine the policies developed by individual hospice programs on program and staff participation in the Washington Death with Dignity Act. This article sets a national and local context for the discussion of hospice involvement in physician-assisted death, summarizes the content of hospice policies in Washington State, and presents an analysis of these findings. The study reveals meaningful differences among hospice programs about the integrity and identity of hospice and hospice care, leading to different policies, values, understandings of the medical procedure, and caregiving practices. In particular, the authors found differences 1) in the language used by hospices to refer to the Washington statute that reflect differences among national organizations, 2) the values that hospice programs draw on to support their policies, 3) dilemmas created by requests by patients for hospice staff to be present at a patient's death, and 4) five primary levels of noninvolvement and participation by hospice programs in requests from patients for physician-assisted death. This analysis concludes with a framework of questions for developing a comprehensive hospice policy on involvement in physician-assisted death and to assist national, state, local, and personal reflection.     

Ministry to Persons with AIDS: A Family Systems Approach. By Robert J. Perelli

This article presents results from a study of all hospice programs in a western state. Personal interviews and questionnaires were utilized to collect data about hospice programs, their directors, nurses, social workers, and chaplains. Results from this study indicate the hospice programs in one state do not uniformly deliver “total care,” services designed to address physical, emotional, social, and spiritual needs. Caseloads for nurses were consistent at 9-12 patients per one Full Time Equivalent (FTE) while caseloads for social workers and chaplains varied widely from less than twenty patients per FTE to more than one hundred for some chaplains. Social workers and chaplains identified lack of time as a significant challenge, while nurses were challenged by the emotional needs of patients and families. Social workers and chaplains were significantly more likely than nurses to view the medical needs of patients as the primary focus of their hospice programs. Further, results indicate that characteristics of programs and directors were related to the availability of services and staff perceptions of hospice practices. [Article copies available from The Haworth Document Delivery Service: 1-800-342-9678. E-mail address: getinfo@haworth.com]     

Doctors' and nurses' perceptions of interdisciplinary collaboration in the NICU, and the impact of a neonatal nurse practitioner model of practice

Background. The importance of interdisciplinary collaboration has been attested to by a number of authors. Some have suggested that Nurse Practitioners (NPs) may be able to improve collaboration between doctors and nurses, but this assertion does not appear to have been researched. Aims and objectives. To investigate doctors’ and nurses’ perceptions of interdisciplinary collaboration in two neonatal intensive care units, and to assess the impact of a Neonatal Nurse Practitioner (NNP) practice model on these perceptions. The study was conducted as part of a larger project to develop a NNP model of practice. Design. Survey, pre‐ and post‐intervention. Methods. Medical and nursing staff in both units were surveyed before and after introduction of the NP model of practice. The instrument consisted of 25 statements relating to nurse–doctor interactions, with which respondents indicated their level of agreement on a five‐point Likert scale. The Mann–Whitney U‐test was used to compare scores for individual items and for overall collaboration between various groups of staff, and between the first and second surveys. Results. Significant differences between the responses of nurses and doctors were found on both surveys. Areas of disagreement chiefly concerned doctors’ behaviour and their attitudes towards nurses, rather than nurses’ behaviour or environmental factors. Doctors consistently reported a higher degree of collaboration than did nurses. Few differences were found between first and second surveys. Conclusions. Results suggest that problems in nurse–physician interactions exist in both units. No impact of the NNP role, as established in this project, on interdisciplinary collaboration could be demonstrated. Further research in this area is warranted.     

Level of RN educational preparation: its impact on collaboration and the relationship between collaboration and professional identity.

This study had a dual purpose: to determine (1) whether level of education (diploma/baccalaureate, master's/doctoral) affects nurses' perceptions of their interprofessional collaboration, and (2) whether there is a relationship between collaboration and professional identity. A stratified random sample of nurses completed a mailed survey assessing 4 dimensions of collaboration (mutual safeguarding of concerns, power/control, clarity of patient-care goals, and practice spheres) and professional identity. Higher level of education was found to impact positively on the first 3 dimensions.Weak relationships between identity and collaboration suggest that higher education levels negatively affect collaboration. Based on these findings, settings relying on interprofessional cooperation would do well to include graduate-prepared nurses in their staff mix, and nurses working in such areas might consider graduate preparation in their career plans. The findings reinforce the need for interprofessional education, particularly at the graduate level.     

Beyond Control: Staff Perceptions of Accountability for Children and Youth in Residential Group Care

This article explores the perceptions of residential staff teams regarding the concept of accountability for children and youth living in group care situations. Using a qualitative research approach, the authors held focus groups with residential staff teams in children's mental health and private group care facilities and then interviewed the supervisors separately in an effort to explore how these teams conceive of their responsibility to teach children and youth about accountability, as well as in order to determine the specific tools used and approaches taken for this purpose. The authors found that a strong reliance on control-based approaches persists and that, furthermore, very little conceptual or theoretical thinking informs team discussions or approaches to holding children and youth accountable for their actions. It is argued here that there is an urgent need to seriously engage with residential care providers about the lived experiences of children and youth under conditions. The use of control and vigilance around the enforcement of program expectations are rarely focused on the individual needs of the clients and typically reflect the intuition or “common sense” of residential staff teams instead.     

Interdisciplinary collaboration in hospice team meetings

Hospice and palliative care teams provide interdisciplinary care to seriously-ill and terminally-ill patients and their families. Care teams are comprised of medical and non-medical disciplines and include volunteers and lay workers in healthcare. The authors explored the perception of collaboration among hospice team members and actual collaborative communication practices in team meetings. The data set consisted of videotaped team meetings, some of which included caregiver participation, and team member completion of a survey. Findings revealed that the team's reflection on process was most likely to occur in team meetings, however least likely to occur when caregivers were present. Although team members had a high perception of interdependence and flexibility of roles, this was less likely to be enacted in team meetings with and without the presence of caregivers. Caregiver participation in team meetings had a positive impact on collaborative communication and the potential benefit of caregiver inclusion in team meetings is explored.     

Timing of referral to hospice and quality of care: length of stay and bereaved family members' perceptions of the timing of hospice referral

Previous research has noted that many persons are referred to hospice in the last days of life. The National Hospice and Palliative Care Organization collaborated with Brown Medical School to create the Family Evaluation of Hospice Care (FEHC) data repository. In 2005, 106,514 surveys from 631 hospices were submitted with complete data on the hospice length of stay and bereaved family member perceptions of the timing of hospice care. Of these surveys, 11.4% of family members believed that they were referred "too late" to hospice. This varied from 0 to 28.1% among the participating hospice programs with 30 or more surveys. Among those with hospice lengths of stay of less than a month, only 16.2% reported they were referred "too late." Although the bereaved family member perceptions of the quality of end-of-life care did not vary by length of stay for each of the FEHC domains, the perception of being referred "too late" was associated with more unmet needs, higher reported concerns, and lower satisfaction. Our results suggest that family members' perception of the timing of hospice referral-not the length of stay-is associated with the quality of hospice care. This perception varies substantially among the participating hospice programs. Future research is needed to understand this variation and how hospice programs are delivering high quality of care despite short length of stay.     

Palliative care in nursing homes: a comparison of high- and low-level providers

The purpose of this study was to explore staff perceptions and concerns about the use of palliative care services in the nursing home setting. Six administrators from nursing homes were purposively selected for key informant interviews. Four common themes emerged, including issues related to the culture of care, the model of care, the relationships with hospice partners, and the role of staff. Recognition of staff perceptions is an important first step in improving the utilization of palliative care services. Staff insight provided clarification related to impediments in promoting a culture of care that was person-centered and relationship-based. We conclude by identifying the solutions for raising the level of dialogue to promote palliative care practice in the nursing home environment.     

Perceptions of an international interprofessional education experience: Findings from students based in Europe and North America

The globalisation of healthcare is changing the demands placed on health professionals. It requires different skills and thought processes across national borders. Thinking in an innovative manner may provide healthcare workers with some of the necessary tools to facilitate international change by increasing students’ mental flexibility and ability to apply solutions in multiple contexts. We created the International Innovation Program for health profession education students to learn about and implement the innovation process. The programme provides students the opportunity to learn in interprofessional, international teams and apply didactic knowledge to community problems using the innovation process. The purpose of this article is to describe student perceptions across 4 years of programme implementation. Through analysis of closed-ended survey data, we found that students who participated in the programme reported improvements in collaboration and teamwork, project management, interprofessional teamwork, professional growth and development, thinking in an innovative manner, research and development skills, information seeking, and willingness to work on international projects. Analysis of the open-ended questions revealed five themes: language, teamwork and collaboration, cultural awareness, innovation process, and personal growth and self-improvement. The long-term, follow-up data indicate that these attributes can be transferred into a clinical context which have implications for improved collaboration and patient care.     

Developing a bereavement services component for an urban teaching hospital's new palliative care program: a four-target survey approach

As more patients die in the hospital under the supervision of palliative care teams, there is a growing interest in hospital-based bereavement services. As part of the palliative care program development at our 463-bed community-based teaching hospital, we conducted a survey of top national palliative care programs, local hospice programs, local funeral homes, and the original staff of the hospital's prior program. The significance of certain data stood out in terms of the planning of delivery of services at our hospital. Three issues were of primary concern to the study team: providing families with services beyond the "minimal" of a single card or telephone call; the position of a bereavement coordinator would be necessary to manage or oversee the delivery of these services; and community volunteer aid was needed to ensure the program's financial viability.     

Nurses' perceptions of interdisciplinary collaboration

The purpose of this study was to statistically characterize nurses' perceptions of the collaboration between nursing and other health disciplines and to examine the relationships among education level, education, experience, and work setting as they relate to the perception of collaboration. The significance of collaboration was conceptually supported by Luszki and Gray's framework of interdisciplinary collaboration. The convenience sample consisted of undergraduate nursing students, licensed practical nurses (LPNs), registered nurses (RNs) pursuing a baccalaureate degree in nursing (BSN), and graduate level BSN-prepared nurses pursuing a master's degree (MSN) in some subspecialty. The findings were significant for an increased level of education and increased perception of collaboration.