Strategies used in improving and assessing the level of reporting of implementation fidelity in randomised controlled trials of palliative care complex interventions: A systematic review

BACKGROUND

Implementation fidelity is critical in evaluating effectiveness of interventions.

AIM

Identifying and summarising strategies to improve and assess the level of reporting of implementation fidelity in randomised controlled trials of palliative care complex interventions.

DESIGN

Systematic review.

DATA SOURCES

Published and completed randomised controlled trials from 2000 to current evaluating effectiveness of specialised palliative care services on patient-centred outcomes in adult patients were examined. MEDLINE was searched from 2008 to 29 September 2015 and supplemented by randomised controlled trials identified in a 2008 systematic review.

RESULTS

Altogether, 20 randomised controlled trials involving 8426 patients were reviewed using 40 subcomponents of five elements of implementation fidelity (resulting in 20 × 40 = 800 items). Over 88 strategies were identified, classified under the following elements: 'treatment design', 'training providers', 'delivery of treatment', 'receipt of treatment' and 'enactment of treatment skills'. No single overarching strategy was discovered. Strategies under 'treatment design' aimed to ensure equivalent treatment dose between and within intervention and control groups, and delivery of necessary ingredients. Ongoing 'training (of) providers' included supervision and ensuring skill acquisition. Use of treatment manuals and implementation checklists aimed to aid 'delivery of treatment'. Research teams aimed to improve 'receipt of treatment' by transmitting clear information and verifying understanding, while improving 'enactment of treatment skills' by reviewing and reinforcing prior content. Only 26% of the items received sufficient reporting; 34% were either not used or reported on.

CONCLUSION

Implementation fidelity in palliative care is under-recognised. A table to collate these strategies to improve implementation fidelity in palliative care research and clinical practice is proposed.

Exploring Nursing Values in the Development of a Nurse-Led Service

This article considers the development of nurse-led services as a part of a pilot study and explores the therapeutic nature of the role of the nurse. In particular it suggests a need for reconsideration of the fundamental values of nurse-led care in the context of changing organizational culture. Within the UK there has been pressure from policy makers to extend the role of the specialist nurse and create new nursing roles, shifting the boundaries between professional health groups. The philosophy of nurse-led initiatives has therefore been driven mainly from a service redesign and clinical need standpoint rather than necessarily focusing on enhancing patients’ experience and the changes in organizational culture required to achieve this. While several studies have focused on the safety, comparative cost and comparative patient outcomes in nurse-led care in relation to traditional or doctor-led care, little attention has been given to the changing organizational values underlying the nursing role. Exploring this context is essential if new nursing roles are to provide more than relief for bottlenecks in the system and also meet their potential for providing patient centred and innovative models of care.

Working together: Crossing discipline boundaries to evaluate complex interventions

Nurses, it is argued, should participate in interdisciplinary research, yet there is little written about working in an interdisciplinary environment in research. This paper sets out some reflections on the experience of a nurse and a health economist working together on a series of studies. A number of difficulties are identified as themes running through the experience of interdisciplinary research: evaluating complex interventions, disruption of normal academic and scientific life, competition between disciplines and teams, finding a common language and learning to work together, finding the common ground and mutual self-interest, and learning to respect other perspectives and disciplines. Rosenfield's (1992) taxonomy of cross-disciplinary research is presented as a model to explain the development of our own approach. A commitment to the goal of transdisciplinarity in research is suggested.

Breast cancer follow-up: Literature review and discussion

This paper presents a review of the evidence for long-term breast cancer follow up to determine if routine clinical review post treatment for breast cancer has benefits for patients. There is little evidence that clinical review of patients beyond 3 years post-diagnosis leads to improved patient survival. Separate to survival there is a dearth of inquiry relating to the value of long-term clinical review of patient in terms of psychological outcomes, quality of life, patient satisfaction, access to specialist advice regarding management of symptoms, and reassurance. Regardless of supporting evidence, most breast units in the UK continue to undertake routine six monthly clinical reviews of patients up to a minimum of 5 years. A literature search for the period 1989 to January 2006 was undertaken using the CINAHL, MEDLINE, and PsychINFO databases. Keywords such as 'cancer follow-up', 'cancer survivorship', and 'psychological outcomes of cancer' were utilised. Hand searching was also undertaken. Overall a paucity of evidence was found in relation to the long-term needs of breast cancer survivors. Alternatives to hospital-based follow-up are reported such as GP or nurse-led follow-up, but the fundamental question of the importance of follow-up in relation to psychological morbidity and quality of life still remains unanswered. Further research is needed to investigate the importance of follow-up to patient survivorship. Research to explore the concept of point of need access, as well as the qualitative experiences of patients post-discharge, informational needs at discharge and on-going psychosocial support is suggested. Ultimately this paper argues for a greater choice and involvement of patients in determining their future follow up needs, providing the patient with a personalised package of care based on risk assessment and subsequent education programmes to empower patients towards self-management following discharge.

Developing and piloting a nurse-led model of follow-up in the multidisciplinary management of colorectal cancer

One of the main challenges of colorectal cancer follow-up is the detection of early disease in order to influence survival and improve outcome. Yet, the benefits of follow-up are not only related to survival. It is well documented that patients can experience an array of problems following colorectal cancer surgery which impact upon quality of life, therefore symptom management plays an important part in the overall spectrum of follow-up care. In addition, there is emerging evidence to suggest that clinical nurse specialists are well placed in the multidisciplinary team to co-ordinate such follow-up programmes. This paper reports on a pilot study designed to assess the feasibility of a follow-up programme led by nurse specialists for patients with colorectal cancer. Key outcome areas were adherence to an agreed follow-protocol, quality of life, patient and clinician satisfaction and a cost-analysis of the new model. The study was conducted over one year with 60 patients. This redesign resulted in a smoother pathway of follow-up care, improved quality of life and acceptance to both patients and clinicians alike. The introduction of a nurse-led follow-up model is expected to demonstrate cost savings over a 3 year rolling follow-up programme.

Guidelines on the role of the specialist nurse in supporting patients with lung cancer

Recently, there has been a significant increase in the number of nurse specialist posts working with patients with lung cancer in the UK. This has been in response to a recognized need to improve lung cancer services. However, there is concern that these posts have been developed quickly with little strategic planning or evaluation. This paper is a collaborative project by the members of The London and South East Lung Cancer Forum for Nurses and aims to offer guidelines to managers and practitioners on areas where improvements may be made in the care of patients with lung cancer. Recommendations are based on Government guidelines, evidence from recent research studies and the experience of the members of the Forum.

Evidence-based practice is a time of opportunity for nursing

The debate regarding evidence-based practice (EBP) continues to rage within nursing. This article reviews the existing situation regarding policy and the ability of nurses to engage with EBP. Recommendations are made regarding moving the debate away from a focus on barriers to EBP towards seizing it as an opportunity. The article suggests that a fundamental change in attitude is required by nurses in order for the nursing profession to progress. There is a need to recognize that the nature of health services are changing and that nurses need to grasp the opportunities this makes available, but in order to do this nurses need support.

The role of nurse-led care in cancer management

Extending nurses' roles and responsibilities so that they may take on some functions of doctors is widely advocated to assist with shortages of medical staff, improve service provision, and to reduce costs. In cancer care in particular, use of specialist nurses to help meet targets for faster diagnosis and treatment is seen as essential. However, there has been little detailed investigation of the consequences, effectiveness, or acceptability of doctor-nurse substitution across health care, or more specifically in cancer services. In this article, I review the evidence for nurse-led care in cancer.

Follow-up for people with cancer: nurse-led services and telephone interventions

BACKGROUND

Questions about the suitability of traditional outpatient follow-up clinics as a way of providing on-going monitoring for patients following serious illness have led to the development of a range of nurse-led services. However, there has been little attempt to draw some of this knowledge together formally and consider the weight of evidence on the necessity and value of nurse-led follow-up.

AIM

To provide a review of literature evaluating the impact of nurse led follow-up in cancer care, with particular focus on the use and value of telephone interventions.

METHOD

A literature search was conducted of nursing, medical and social science databases and the following keywords: cancer follow-up, nurse-led follow-up, telephone follow-up, telephone-based interventions and telephone survey. The search yielded over 150 papers, of which 37 were relevant to this review.

FINDINGS

The literature suggests that nurse-led follow-up for people with cancer meets their needs for psychological support and information. The telephone is identified as a suitable means of providing this kind of service.

CONCLUSION

This review demonstrates that nurse-led follow-up services are acceptable, appropriate and effective. Combined with use of the telephone, such services can be an efficient means of maintaining contact with a large client group, providing vital support to vulnerable patients during their move into aftercare and beyond.

Nurses’ experiences of cancer

This paper provides an overview of research into nurses' experiences of working with cancer, both how nursing care is experienced by people with cancer and the effects on nurses of working in cancer treatment and care settings. The literature, although slim, suggests that the work of nurses is experienced as valuable and supportive, although this is not consistently the case. Although nurses find working with people with cancer rewarding, it is also emotionally demanding. Evidence for stress among nurses working in cancer settings is mixed and may be related to structural factors more than the difficulties of working with patients who may be dying, although this warrants further exploration. Studies of nurses' communication skills are limited by a measurement-orientated approach that measures behaviour against predetermined criteria. Observational studies provide rich insights into the complex relationship between how nurses work with people who have cancer, or who are dying, as they adjust to their predicament, how this is therapeutic, but also where it may go wrong. Little detailed or comparative work has been undertaken into the skills and experiences of nurses working in different roles, in particular those of nurse specialists. Research is needed to further elucidate themes identified, in particular to shed light on how nurses and other health professionals may be assisted to develop expert practice in working with cancer, but also to sustain health professionals in this work.