AIM: The aim of this study was to describe team leaders' experiences of facilitators and barriers of leadership in specialist palliative home care teams.
BACKGROUND: For effective teamwork in specialist palliative care, leadership is crucial; however, defining and agreeing on what leadership comprises may be challenging. In palliative care, teamwork is recognized as imperative for multiprofessional perspectives to meet dying patients' and families' needs.
METHODS: Qualitative interviews with 13 team leaders in specialist palliative home care were performed, using the Pettigrew and Whipp framework, and analysed with directed content analysis.
RESULTS: Team leaders' experiences of conditions influencing the organisation and delivery of specialist palliative home care is multifaceted and leaders seem conflicted in their approach to the multiple levels of leadership, vision and responsibilities.
CONCLUSION: Team leaders in specialist palliative home care described goals of care on differing levels and, for some, fiscal restraints and external pressures influenced their vision and leadership. Team leaders experienced challenges of leadership in relation to organisational issues, feeling burdened by responsibilities, budget restraints and team size.
IMPLICATIONS FOR NURSING MANAGEMENT: Team leadership is demanding and complex. In specialist palliative home care, affirming values and enabling vision during times of fiscal strain and external pressures, is challenging. For successful leadership that develops both individuals and the health care team, leaders are recommended to adapt the leadership style to the present situation surrounding the team.
Les codes sous-jacents de la démarche palliative, d’une part, et du management, d’autre part, pourraient paraître antinomiques. Pourtant, l’exercice des managers au sein d’un établissement de santé ou du médico-social est censé côtoyer les principes du care comme mode relationnel avec ses employés. Cet article retrace la genèse de ce questionnement né de la sollicitation d’enseigner les soins palliatifs à des futurs directeurs. En effet, la pratique pédagogique nous a amenés à considérer les soins palliatifs non seulement comme un contenu d’enseignement, mais comme un potentiel modèle managérial intégrant à la fois une vision de co-construction des projets, une implication à tous les niveaux des professionnels, l’empathie dans la relation et la prise en compte de l’impossible.
Prendre son premier poste d'infirmier coordonnateur en Service de soins infirmiers à domicile est un moment nécessitant un encadrement particulier. Des compétences d'encadrement et de gestion sont à acquérir. L'accompagnement par le pair, étant donné la spécificité de ce service, semble obligatoire. Les communautés de pratique peuvent être un appui. L'enjeu de ce travail de recherche est d'étudier en quoi les communautés de pratique sont devenues un accompagnant de la professionnalisation du primo-encadrant en SSIAD ?
[Extrait résumé auteure]
Le déploiement du Système d'Information et du Dossier Patient informatisé suscite craintes et interrogations au sein de l'Hôpital. Le rôle d'accompagnement du cadre de santé est alors essentiel. L'élaboration d'objectifs nécessite une stratégie qui repose sur différents leviers. La phase exploratoire a permis d'établir trois hypothèses répondant à : en quoi une stratégie dans l'accompagnement influence le déploiement du Dossier Patient informatisé ?
Une enquête basée sur une approche qualitative tend à les confirmer ou réfuter. L'étude repose sur l'analyse d'entretiens avec des cadres de santé. A l'issue, il s'avère que le diagnostic est une phase importante pour l'adaptation de l'accompagnement. La responsabilisation, l'implication des professionnels sont de véritables leviers. Cependant la finalité qui favorise l'adhésion n'est pas toujours celle autour de la prise en charge du patient mais plutôt la traçabilité et l'utilisation pratique. Deux autres leviers ont également été éclairés.
Ce mémoire réflexif vient ponctuer deux années riches en partage, en émotions et aussi en introspection. Il part d'une situation managériale complexe qui m'a mise à mal et a fait écho à ma vie personnelle. Elle est venue questionner la vision d'exemplarité que j'avais de ma fonction. En étudiant les concepts des attendus de la fonction cadre, de la vulnérabilité et du mémoire réflexif, je me suis rendue compte que la vulnérabilité n'était pas une faille mais pouvait devenir une force dans les relations humaines si elle est adaptée. Le dernier chapitre est réservé aux déploiements possibles de mes constatations dans ma pratique actuelle : démarche palliative, amélioration du travail pluri professionnel et création d'un temps d'analyse éthique.
Nurses who care for patients with life-limiting illness operate at the interface of family caregivers (FCGs), patients, and prescribers and are uniquely positioned to guide late-life medication management, including challenging discussions about deprescribing. The study objective was to describe nurses’ perspectives about their role in hospice FCG medication management. Content analysis was used to analyze qualitative interviews with nurses from a parent study exploring views on medication management and deprescribing for advanced cancer patients. Ten home and inpatient hospice nurses, drawn from 3 hospice agencies and their referring hospital systems in New England, were asked to describe current practices of medication management and deprescribing and to evaluate a pilot tool to standardize hospice medication review. Analysis of the 10 interviews revealed that hospice nurses are receptive to a standardized approach for comprehensive medication review upon hospice transition and responded favorably to opportunities to discuss medication discontinuation with FCGs and prescribers. Effective framing for discussions included focus on reducing harmful and nonessential medications and reducing caregiver burden. Results indicate that nurses who care for hospice-eligible and enrolled patients are willing to discuss deprescribing with FCGs and prescribers when conversations are framed around medication harms and their impact on quality of life.
INTRODUCTION: Very little has been written on seizure management in palliative care (PC). Given this situation, and considering the forthcoming setting up of the Palliative Care Unit at our neurorehabilitation centre, the Clínica San Vicente, we decided to establish a series of guidelines on the use of antiepileptic drugs (AEDs) for handling seizures in PC.
METHODS: We conducted a literature search in PubMed to identify articles, recent manuals, and clinical practice guidelines on seizure management in PC published by the most relevant scientific societies.
RESULTS: Clinical practice guidelines are essential to identify patients eligible for PC, manage seizures adequately, and avoid unnecessary distress to these patients and their families. Given the profile of these patients, we recommend choosing AEDs with a low interaction potential and which can be administered by the parenteral route, preferably intravenously. Diazepam and midazolam appear to be the most suitable AEDs during the acute phase whereas levetiracetam, valproic acid, and lacosamide are recommended for refractory cases and long-term treatment.
CONCLUSIONS: These guidelines provide general recommendations that must be adapted to each particular clinical case. Nevertheless, we will require further well-designed randomised controlled clinical trials including large samples of patients eligible for PC to draft a consensus document recommending adequate, rational, and effective use of AEDs, based on a high level of evidence, in this highly complex area of medical care.
PURPOSE: The purpose of this study was to explore compassionate leadership with those involved in leading system-wide end-of-life care. Its purpose was to: define compassionate leadership in the context of palliative and end-of-life care; collect accounts of compassionate leadership activity from key stakeholders in end-of-life and palliative care; and identify examples of compassionate leadership in practice.
DESIGN/METHODOLOGY/APPROACH: Four focus groups involving staff from a range of healthcare organisations including hospitals, hospices and community teams were conducted to access the accounts of staff leading palliative and end-of-life care. The data were analysed thematically.
FINDINGS: The themes that emerged from the data included: the importance of leadership as role modelling and nurturing; how stories were used to explain approaches to leading end-of-life care; the nature of leadership as challenging existing practice; and a requirement for leaders to manage boundaries effectively. Rich and detailed examples of leadership in action were shared.
RESEARCH LIMITATIONS/IMPLICATIONS: The findings indicate that a relational approach to leadership was enacted in a range of palliative and end-of-life care settings.
PRACTICAL IMPLICATIONS: Context-specific action learning may be a means of further developing compassionate leadership capability in palliative and end-of-life care and more widely in healthcare settings.
ORIGINALITY/VALUE: This paper presents data indicating how compassionate leadership, as a form of activity, is envisaged and enacted by staff in healthcare.
PROBLEM: Despite acknowledged benefits, the impact of advance care planning on usual care is inconsistent.
DESIGN: Quality improvement study.
SETTING: A Western Australian regional hospital.
KEY MEASURES FOR IMPROVEMENT: This project aimed to create a system for storing, accessing and incorporating advance care planning documents in clinical care.
STRATEGIES FOR CHANGE: Interventions over 18 months addressed four areas: medical records processes for receiving and processing advance care planning documents; information technology solutions for electronic storage and alerts; clerical staff duties in regards advance care planning documents; and clinician education.
EFFECTS OF CHANGE: There was a 12-fold increase in advance care planning documents stored electronically and 100% of audited notes had correct filing of advance care planning documents with an alert in place at follow-up audit. Clinician recognition of the presence of an advance care planning document improved. Detailed examples of interventions are described.
LESSONS LEARNT: Repeated exposure to different forms of advance care planning education, in conjunction with simple but effective system changes can make a difference in changing established hospital practice. Final impact of these changes on end-of-life care requires further audit.
Liliana de Lima, Executive Director of the International Association for Hospice & Palliative Care (IAHPC), begins by telling me about all the other people I should be interviewing. Her passion for her work and admiration for her colleagues run throughout our conversation, and it soon becomes apparent that the “emotional reasons and rational reasons”, as she calls them, have defined her career.
Successful advance care planning relies heavily on effective communication between the elderly and their families, care managers, and social workers. However, care managers and social workers are often not adequately prepared to conduct such discussion. The aim of the present study was to identify the specific challenges facing Japanese care managers and social workers when involvement in advance care planning. Two focus group discussions were held between August and November 2017, involving eleven care managers and three social workers employed at two long-term care facilities actively pursuing advance care planning initiatives. Four main themes were identified, through content analysis, as barriers and facilitators: client readiness, communication, variation-rich client individuality, and difficult-to-explain end-of-life options. This study revealed the importance of building rapport with the residents and their families in order to assess their readiness to discuss care options and preferences. Obstacles included lack of medical knowledge of care managers and social workers. Study findings suggested that a multi-disciplinary team, facilitated by care managers and social workers, was fundamental to achieving the goals of advance care planning.
L’épuisement professionnel des soignants est particulièrement fréquent en cancérologie. Ses causes en sont plurifactorielles, car relevant quasiment toujours de l’association de facteurs personnels et professionnels. Ceux liés au travail peuvent être séparés en cinq catégories : le type de travail, la charge de travail, les conflits interpersonnels, les facteurs organisationnels et les facteurs managériaux. La qualité de vie au travail est un concept plus récent qui s’inscrit dans le champ de la psychologie positive. La démarche participative est un modèle organisationnel qui reposait initialement sur quatre composantes : la formation interne, les staffs pluriprofessionnels, le soutien aux équipes et la démarche projet. Récemment nous avons rajouté une cinquième composante devant le constat de la nécessité d’espaces d’échanges entre les médecins et les cadres de santé des services pour que le modèle marche. Ce modèle est un critère prioritaire HAS d’accréditation des établissements depuis la V 2010 pour la prise en charge des patients en soins palliatifs dans tous les services de soins. Dans la dernière partie de cet article nous verrons l’impact des facteurs managériaux et organisationnels mais également du modèle organisationnel de la démarche participative sur la qualité de vie au travail des soignants et sur la qualité des soins offerts aux patients et à leurs proches.
Introduction: Very little has been written on seizure management in palliative care (PC). Given this situation, and considering the forthcoming setting up of the Palliative Care Unit at our neurorehabilitation centre, the Clínica San Vicente, we decided to establish a series of guidelines on the use of antiepileptic drugs (AEDs) for handling seizures in PC.
Methods: We conducted a literature search in PubMed to identify articles, recent manuals, and clinical practice guidelines on seizure management in PC published by the most relevant scientific societies.
Results: Clinical practice guidelines are essential to identify patients eligible for PC, manage seizures adequately, and avoid unnecessary distress to these patients and their families. Given the profile of these patients, we recommend choosing AEDs with a low interaction potential and which can be administered by the parenteral route, preferably intravenously. Diazepam and midazolam appear to be the most suitable AEDs during the acute phase whereas levetiracetam, valproic acid, and lacosamide are recommended for refractory cases and long-term treatment.
Conclusions: These guidelines provide general recommendations that must be adapted to each particular clinical case. Nevertheless, we will require further well-designed randomised controlled clinical trials including large samples of patients eligible for PC to draft a consensus document recommending adequate, rational, and effective use of AEDs, based on a high level of evidence, in this highly complex area of medical care.
Palliative care has demonstrated effectiveness in alleviating the biological, emotional, social, and spiritual symptoms that accompany serious illness, and improving quality of life for seriously ill individuals and their family members. Despite increasing availability, there are significant disparities in access to and utilization of palliative care, particularly among diverse, low-income, and community-dwelling older adults with chronic illness. Training frontline service providers is a novel approach to expanding access to palliative care among underserved elders. This article presents a process and outcome evaluation of a palliative care curriculum that was developed and piloted for geriatric case managers in a large urban area. We describe the background, planning, design, implementation, and preliminary outcomes associated with a pilot implementation of the curriculum. We conclude with implications for replicating efforts to enhance frontline providers' knowledge, skills, and self-efficacy in extending palliative care to communities that lack access to critical supports for their burdensome symptoms.
BACKGROUND: There is very little research into the way that offender management strategies impinge on the practices and decision-making of palliative care personnel in community settings.
AIMS: To improve understanding of the challenges that community palliative care service providers encounter when caring for people who have been sentenced to custody and are under the supervision of the prison or probation services.
METHODS: This paper discusses one part of a larger multidisciplinary study on bereavement, loss and grief in the criminal justice system. It reports the findings from a focus group with 10 health professionals working within specialist community palliative care services. Thematic analysis was undertaken to identify and explicate the most significant themes arising from the transcript data.
RESULTS: There were situations where the participants were able to identify that patients were under the jurisdiction of the criminal justice system or had relatives in custody. Three themes emerged that highlighted distinctive aspects of providing care to this patient group. These themes were: patients under prison, probation or police supervision altered the dynamics of care provision; prisoners were restricted from supporting or contacting their dying relatives in the community; and participants (professionals) were obstructed from supporting patients at home because of criminal or antisocial behaviour by relatives of the dying.
CONCLUSIONS: Health professionals face multiple challenges that curtail them from fully realising the aims of palliative care for patients and relatives under criminal justice supervision, in ways that merit further consideration and research.
Palliative care has long been described in medical literature but only recently is being discussed in the surgical domain. Mounting evidence suggests that early integration of palliative care improves patient outcomes and this is especially true of oncology patients. Thus, the pendulum is swinging toward recognizing that palliative care and active disease management are not mutually exclusive but rather synergistic in modern surgical oncology. Here we use a patient vignette to demonstrate the new challenges and possibilities in modern surgical oncology, we then discuss the historic perspective of palliative care and describe how the paradigm is shifting. Finally, we introduce a model that may be beneficial in conceptualizing this new way of thinking about and integrating palliative care into surgical oncology.
This article attempts to examine and explore the change management process that was undertaken by the community palliative care service at Calvary Health Care Bethlehem, Australia, to challenge the historical practice of prescribing 'emergency subcutaneous medications' for all patients admitted to the service. It discusses how, using a team approach, change management was effectively facilitated to ultimately enhance service provision and consumer satisfaction. Literature (both national and international) was examined to identify the use of emergency medications in the community palliative care setting. The historical practice of all community palliative care patients being prescribed this medication within the Victoria region of Australia was tested, and concerns and misconceptions of staff and referrers were challenged in regards to this practice. Through working parties, descriptive surveys and staff evaluations, the use of the term 'emergency medication' was changed to 'anticipatory medication' with clear criteria for usage. Change was undertaken slowly and with continued collaboration of staff to ensure effectiveness. Staff survey results identified that the majority were satisfied with the change, and they considered there to be no impact on the quality of care that their patients were receiving. The natural progression of the project, which resulted in positive quantitative and qualitative results, was the facilitation of an education package for carers to educate them on giving subcutaneous medications to the patient. By undertaking change that was slow and methodical with clear communication to all, the community palliative care service was able to embed the changes into everyday practice, and the use of anticipatory medications within the Calvary Health Care Bethlehem community palliative care service is now understood, acknowledged, and adhered to by all staff.
BACKGROUND: Do-not-resuscitate (DNR) orders instruct medical personnel to forego cardiopulmonary resuscitation in the event of cardiopulmonary arrest, but they do not preclude surgical management. Several studies have reported that DNR status is an independent predictor of 30-day mortality; however, the etiology of increased mortality remains unclear. We hypothesized that DNR patients would demonstrate increased postoperative mortality, but not morbidity, relative to non-DNR patients undergoing the same procedures.
METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database for 2007-2013, we performed a retrospective analysis to compare DNR and non-DNR cohorts matched by the most common procedures performed in DNR patients. We employed univariable and multivariable logistic regression to characterize patterns of care in the perioperative period as well as identify independent risk factors for increased mortality and assess for the presence of "failure to rescue."
RESULTS: The most common procedures performed on DNR patients were emergent and centered on immediate symptom relief. When adjusting for preoperative factors, DNR patients were still found to have increased incidence of postoperative mortality (odds ratio 2.54 [2.29-2.82], P < .001) but not postoperative morbidity at 30 days. In addition, cardiopulmonary resuscitative measures and unplanned intubation were found to be less frequent in the DNR cohort.
CONCLUSIONS: These findings suggest that increased mortality is the result of adherence to goals of care rather than "failure to rescue."
At least one-third of patients at the end of life (EOL) receive interventions that are without benefit, and a similar proportion of patients die in the intensive care unit. Here, the authors discuss the role of antimicrobials in patients at the EOL, including the patient populations and scenarios in which antimicrobials may or may not have benefit. They also review adverse outcomes associated with antimicrobial use at the EOL, including societal harms. Finally, an algorithm to aid management of suspected infections at the EOL is proposed.