Palliative care nurse champions' views on their role and impact: a qualitative interview study among hospital and home care nurses

Dimensions and components of hospital-at-home care: a systematic review

BACKGROUND AND AIM

Hospital-at-home (HaH) care is known as a healthcare delivery approach providing acute care services at home as an alternative to traditional hospital care. This study aimed to explore the dimensions and components of HaH care.

METHODS

A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The databases including ScienceDirect, Scopus, PubMed, the Cochrane library, the Web of Science Core Collection, and the Wiley online library were searched for articles on HaH care dimensions and components of from early 2000 to February 19, 2024. The inclusion criteria of the study included articles published in the English language, and and those pertaining to various dimensions and components of HaH care. The quality of the studies was assessed using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist and data were analysed using the framework analysis method.

RESULTS

A total of 4078 articles were retrieved. After screening and quality assessment, 179 articles were included in the review, identifying 88 dimensions and components of HaH care across seven main categories: benefits, challenges and obstacles, facilitators, management-related factors, medical conditions, factors associated with patients and their families, and factors associated with caregivers. The common components included cost savings (n = 30), patient and family satisfaction (n = 23), reduction in re-admissions (n = 13), medication management (n = 12), communication, coordination, and cooperation among healthcare teams, patients, and families (n = 12), preferences of patients and families (n = 12), and education of patients, families, and healthcare teams (n = 10).

CONCLUSION

Based on the results, HaH includes many and diverse dimensions and components. So, healthcare policymakers and planners are urged to consider the dimensions and components of HaH care including benefits, challenges and obstacles, facilitators, management-related factors, medical conditions, factors associated with patients and their families, and factors associated with caregivers when developing models and programs to ensure effective outcomes following implementation.

The centrality of nursing in realizing high quality palliative care: Exploring Canada's framework on palliative care priorities

BACKGROUND

Following an earlier mixed-method survey in which we asked stakeholders to report on their perceptions of the progress made in relation to Canada's Framework on Palliative Care and Action Plan, the purpose of this study was to conduct an in-depth qualitative exploration of the factors influencing that progress, or lack thereof.

METHODS

This was a qualitative interview study conducted in Canada. Inclusion criteria included experience with palliative care in Canada in a professional or volunteer capacity. Interviews were conducted by telephone using an interview guide that asked specific questions in relation to the Framework on palliative care priorities (e.g., education, caregiver support, and equitable access). Data was analyzed using qualitative descriptive methods.

RESULTS

Thirty-five diverse stakeholders with extensive experience in palliative care were interviewed. In relation to palliative education, participants indicated that although there were excellent palliative care resources available across the country there was further need for embedding palliative care in undergraduate education and for mentored opportunities to engage in care across diverse contexts. The identification, development, and strategic positioning of champions was an important strategy for improving palliative care knowledge and capacity. The development of standard competencies was viewed as an important step forward; although, there was a need to include more members of the care-team and to create pathways for life-long learning. In relation to support for family caregivers, even as participants cited numerous community-based resources offered by not-for-profit organizations, they described significant barriers including a shortage of in-home support, lack of understanding of what caregivers do, and policy-based contractual and privacy issues. In relation to palliative care access, participants described a nurse-centered, consult-based, multi-site and multi-provider model of care that was facilitated by technology. Barriers to this model were systemic healthcare issues of siloed, fragmented, and for-profit care.

CONCLUSION

Participants in this study had clear insights into the factors that would support or impede progress to the development of palliative care in Canada. Some of those factors were achievable within current health and educational systems. Other factors were going to require longer term and more comprehensive solutions.

End-stage heart failure patients in ICU: the importance of advance planning and effective communication

During the disease trajectory, patients with advanced heart failure are often hospitalised with a high probability of admission to the intensive care setting. Using a case study, this article explores the care given to a patient with decompensated heart failure in an intensive care unit (ICU). It will discuss the significance of holistic assessment and effective symptom management, in particular the research related to breathlessness management. The importance of effective communication within the ICU multidisciplinary team, including with the patient/family will be explored, as the ICU environment can often lead to communication breakdown, patients being unable to voice their wishes and over-medicalisation. The effectiveness of early involvement of the palliative care team in ICU will be examined, including the use of tools such advance care planning and a treatment escalation plan and whether use of these can enable a better patient and family experience at the end of life. The role of palliative care champions will be discussed.

Experiences with a national team-based learning program for advance care planning in pediatric palliative care

BACKGROUND

Advance Care Planning (ACP) enables patients and relatives to define and share values, goals and preferences for future medical treatment and care. The IMplementing Pediatric Advance Care Planning Toolkit (IMPACT), developed in the Netherlands, is a method for conducting ACP in pediatric palliative care. Healthcare professionals who were trained to use IMPACT, indicated their need for ongoing support to practice ACP communication skills optimally over time. Therefore, we developed a team-based learning program aimed at teaching participants how to transfer knowledge on ACP, continue practicing ACP communication skills and reflect on ACP conversations within their own team context. The aim of this study was to evaluate the program's transfer of knowledge as well as the professionals' experience and team reflection on ACP.

METHODS

A one-day IMPACT train-the-trainer course was developed and a selection of healthcare professionals (facilitators) from pediatric palliative care teams (PPCTs) from all seven Dutch university hospitals and the specialized Center for Pediatric Oncology were invited to participate. Hereafter, facilitators were asked to transfer their course-acquired knowledge to their team members (learners) by organizing two coaching-on-the-job sessions. A mixed-methods design, combining questionnaires and field notes, was used to evaluate the level of knowledge transfer and team reflection achieved.

RESULTS

Eighteen healthcare professionals in the role of facilitator participated in the train-the-trainer course. In seven PPCTs one (n = 3) or two (n = 4) coaching-on-the-job session(s) took place, attended by 29 and 17 learners, respectively. In the questionnaires, 11 facilitators indicated that they had to some extent transferred acquired knowledge to their team members as intended. Sixteen out of 21 learners who participated in at least one coaching-on-the-job session, reported (somewhat) increased self-confidence for conducting ACP conversations. The reported main strength of the program was practicing with/learning from colleagues whereas dealing with workload and variation in existing ACP skills within PPCTs need more attention.

CONCLUSIONS

The newly developed team-based learning program resulted in intended transfer of knowledge and methodical reflection on ACP in coaching-on-the-job sessions in most participating PPCTs. Planning coaching-on-the-job sessions regarding ACP in pediatric palliative care with multiple healthcare professionals is challenging and needs more emphasis in the training.

Specialized expertise among healthcare professionals in palliative care - A scoping review

BACKGROUND

The generalist-plus-specialist palliative care model is endorsed worldwide. In the Netherlands, the competencies and profile of the generalist provider of palliative care has been described on all professional levels in nursing and medicine. However, there is no clear description of what specialized expertise in palliative care entails, whereas this is important in order for generalists to know who they can consult in complex palliative care situations and for timely referral of patients to palliative care specialists.

OBJECTIVE

To gain insight in the roles and competencies attributed to palliative care specialists as opposed to generalists.

METHODS

A scoping review was completed based on PRISMA-ScR guidelines to explore the international literature on the role and competence description of specialist and expert care professionals in palliative care. Databases Embase.com, Medline (Ovid), CINAHL (Ebsco) and Web of Science Core Collection were consulted. The thirty-nine included articles were independently screened, reviewed and charted. Thematic codes were attached based on two main outcomes roles and competencies.

RESULTS

Five roles were identified for the palliative care specialist: care provider, care consultant, educator, researcher and advocate. Leadership qualities are found to be pivotal for every role. The roles were further specified with competencies that emerged from the analysis. The title, roles and competencies attributed to the palliative care specialist can mostly be applied to both medical and nursing professionals.

DISCUSSION

The roles and competencies derived from this scoping review correspond well with the seven fields of competence for medical/nursing professionals in health care of the CanMEDS guide. A specialist is not only distinguished from a generalist on patient-related care activities but also on an encompassing level. Clarity on what it entails to be a specialist is important for improving education and training for specialists.

CONCLUSION

This scoping review adds to our understanding of what roles and competencies define the palliative care specialist. This is important to strengthen the position of the specialist and their added value to generalists in a generalist-plus-specialist model.

Acute palliative care models: scoping review

OBJECTIVE

The goal of this scoping review is to identify the most commonly used models of palliative care delivery in acute care settings, their advantages and disadvantages, and to review existent research evidence in support of each model.

METHODS

We conducted an extensive search using EMBASE, Medline, CINAHL and Pubmed, using various combinations of terms relating to models in palliative care and acute care settings. Data were analysed using tabular summaries and content analysis.

RESULTS

41 articles were analysed. Four models were identified: primary, consultative, integrative and hybrid models of palliative care. All four models have varying characteristics in terms of access to specialist palliative care; fragmentation of healthcare services; therapeutic relationships between patients and providers; optimal usage of scarce palliative care resources; timing of provision of palliative care; communication and collaboration between providers and clarity of provider roles. Moreover, all four models have different patient outcomes and healthcare utilisation. Gaps in research limit the ability to determine what model of care is more applicable in an acute care setting.

CONCLUSION

No ideal model of care was identified. Each model had its advantages and disadvantages. Future work is needed to investigate which setting one model may be better than the other.

Emergency medical services: the next linking asset for public health approaches to palliative care?

Emergency medical services (EMS) are a unique workforce providing 24/7 emergency care across high-income countries (HICs) and low- and middle-income countries (LMICs). Although traditionally perceived as first responders to traumatic and medical emergencies, EMS scope of practice has evolved to respond to the changing needs of communities, including a growing demand for community-based palliative care. Public health provides a useful framework to conceptualise palliative and end-of-life care in community-based settings. However, countries lack public policy frameworks recognising the role EMS can play in initiating palliative approaches in the community, facilitating goals of care at end of life and transporting patients to preferred care settings. This article aims to explore the potential role of EMS in a public health palliative care approach in a critical discussion essay format by (1) discussing the utility of EMS within a public health palliative care approach, (2) identifying the current barriers preventing public health approaches to EMS palliative care provision and (3) outlining a way forward through priorities for future research, policy, education and practice. EMS facilitate equitable access, early provision, expert care and efficacious integration of community-based palliative care. However, numerous structural, cultural and practice barriers exist, appearing ubiquitous across both HICs and LMICs. A Public Health Palliative Care approach to EMS Framework highlights the opportunity for EMS to work as a linking asset to build capacity and capability to support palliative care in place; connect patients to health and community supports; integrate alternative pathways by engaging multidisciplinary teams of care; and reduce avoidable hospital admissions by facilitating home-based deaths. This article articulates a public health approach to EMS palliative and end-of-life care provision and offers a preliminary framework to illustrate the components of a potential implementation and policy strategy.

The introduction of a palliative care link nurse programme to improve nurses’ attitudes, knowledge and confidence in providing end-of-life care in an acute care setting

Background: Providing end-of-life (EOL) care in the acute care setting has been challenging, with clinicians focused on curative treatments and prolonging life, while few nurses are receiving adequate training and support in caring for the dying. Aims: To assess if the introduction of a palliative care link nurse programme (PCLNP) improved nurses’ confidence in providing EOL care in the acute care setting. Methods: A total of 40 acute care nurses attended a full-day education session on core topics, followed by regular 3-monthly educational meetings. Participants were provided with ongoing support and mentoring and required to complete quality improvement activities. A mixed-research methodology was used. Findings: The PCLNP had a positive impact on nurses’ attitudes towards death and dying, and increased levels of comfort in providing EOL care to patients and supporting families. Nurses completed clinical audits and provided education to their colleagues. Conclusions: EOL care in this setting must be improved for both patients and their families. This programme has shown an increase in nurses’ knowledge and comfort level in providing EOL care. Further research into determining the direct impact on patient care and families is required.

Neonatal Nurses' Perceptions and Needs of End-of-Life Care Practice: A Jordanian Qualitative Study

End-of-life (EOL) care for newborns is challenging and requires well-prepared nurses to provide the best care for the dying baby and to prepare and support parents during such a difficult experience. This study aimed to explore Jordanian neonatal intensive care unit nurses' perceptions and needs regarding the provision of EOL care. This study used an exploratory descriptive qualitative approach and was conducted among a sample of 12 Jordanian neonatal intensive care unit nurses. Semistructured interviews were conducted to allow the nurses to describe their personal experiences and express their needs related to the provision of EOL care. Two main themes and 6 subthemes emerged from the analysis process. Main themes were (1) the challenges related to the provision of EOL care, and (2) nurses' needs: what matters most. The findings of this study shed light on neonatal care unit nurses' experiences and needs related to the provision of EOL care. The results of this study may be used to develop EOL care guidelines, programs, and protocols to be applied in intensive care units.

Nurse champions as street-level bureaucrats: Factors which facilitate innovation, policy making, and reconstruction

Background

Nurse champions are front-line practitioners who implement innovation and reconstruct policy.

Purpose

To understand through a network theory lens the factors that facilitate nurse champions’ engagement with radical projects, representing their actions as street-level bureaucrats (SLBs).

Materials and methods

A personal-network survey was employed. Ninety-one nurse champions from three tertiary medical centers in Israel participated.

Findings

Given high network density, high levels of advice play a bigger role in achieving high radicalness compared with lower levels advice. High network density is also related to higher radicalness when networks have high role diversity.

Discussion

Using an SLB framework, the findings suggest that nurse champions best promote adoption of innovation and offer radical changes in their organizations through professional advice given by colleagues in their field network. Healthcare organizations should establish the structure and promote the development of dense and heterogeneous professional networks to realize organizations’ goals and nurses’ responsibility to their professional employees, patients, and society.

Moral distress among nurses involved in life-prolonging treatments in patients with a short life expectancy: A qualitative interview study

OBJECTIVE

To explore whether nurses in hospital settings experience moral distress when involved in potentially life-prolonging treatments in adults with a short life expectancy.

METHODS

A qualitative study using semi-structured interviews.

RESULTS

23 Registered nurses working in inpatient or outpatient hospital settings participated. The nurses stated they were often not involved in decisions regarding life-prolonging treatments. They reported signs of moral distress such as feeling powerless when they when they were not being listened to in the decision-making process and when confronted with negative treatment outcomes. Nurses felt frustrated when their own values were not reflected in the decision-making or when physicians created unrealistic expectations.

CONCLUSIONS

Hospital nurses experience moral distress when they are involved in life-prolonging treatment because of the patient's advanced condition and their own lack of involvement in the decision-making process about the treatment. In these situations, moral distress is characterised by feelings of powerlessness and frustration.

PRACTICE IMPLICATIONS

Nurses need to be empowered by training programmes that focus on an active role in the decision-making process. Further research is needed to evaluate effective tools and training programmes that help nurses in shared decision-making processes.

Ongoing Value and Practice Improvement Outcomes from Pediatric Palliative Care Education: The Quality of Care Collaborative Australia

PURPOSE

Novice and experienced professionals who care for children with life limiting conditions throughout Australia were provided with pediatric palliative care (PPC) education through the Quality of Care Collaborative Australia (QuoCCA). Impact evaluation has shown this education to be beneficial. This study examines the longer term outcomes reported by the participants more than 4 months following education.

METHODS

An online survey measuring quantitative and qualitative education outcomes was sent to all participants of QuoCCA 2 education throughout Australia, at least 4 months following their education. There were 152 respondents between February 2018 and June 2020.

RESULTS

More than 4 months after the QuoCCA education, 98% of respondents rated it as extremely valuable or valuable and 78% of respondents rated it extremely or very helpful in improving clinical practice. Improvements in knowledge, skills or confidence were reported by 90% or more respondents in the areas of PPC referral, responding to psychosocial needs, the benefits of the PPC approach, PPC resources and communication skills. Between 84% and 89% of respondents reported improvements in advance care planning, assessment and intervention, responding to physical needs, supporting spiritual needs and supporting health professionals and self care. Providing bereavement care improved in 85% of responses. The most valuable aspects of the education, changes in practice and barriers to the implementation of learning were discussed.

CONCLUSION

The interprofessional QuoCCA education in PPC continued to provide value and clinical practice improvements for the majority of respondents more than four months after the session. Respondents particularly mentioned improvements in awareness of the network of care, the practical management of patients and communication skills. Reflection on clinical practice, in a proactive clinical learning environment, enabled the translation of education into improvements to the quality of PPC.