Ethical dilemmas faced by hospice nurses when administering palliative sedation to patients with terminal cancer.

Objective: Palliative sedation is a method of symptom management frequently used in hospices to treat uncontrolled symptoms at the end of life. There is a substantial body of literature on this subject; however, there has been little research into the experiences of hospice nurses when administering palliative sedation in an attempt to manage the terminal restlessness experienced by cancer patients. Method: Semistructured interviews were conducted with a purposive sample of seven hospice nurses who had cared for at least one patient who had undergone palliative sedation within the past year in a hospice in the south of England in the United Kingdom. A phenomenological approach and Colaizzi’s stages of analysis were employed to develop themes from the data. Results: Facilitating a “peaceful death” was the primary goal of the nurses, where through the administration of palliative sedation they sought to enable and support patients to be “comfortable,” “relaxed,” and “calm” at the terminal stage of their illness. Ethical dilemmas related to decision making were a factor in achieving this. These were: medication decisions, “juggling the drugs,” “causing the death,” sedating young people, the family “requesting” sedation, and believing that hospice is a place where death is hastened. Significance of results: Hospice nurses in the U.K. frequently encounter ethical and emotional dilemmaswhen administering palliative sedation. Making such decisions about using palliative sedation causes general discomfort for them. Undertaking this aspect of care requires confidence and competence on the part of nurses, and working within a supportive hospice team is of fundamental importance in supporting this practice

‘And so I took up residence’:The experiences of family members of people with dementia during admissionto an acute hospital unit

open access articleIt is estimated that a quarter of acute hospital beds are in use by older people with dementia at any one time. Little empirical research has been carried out that has specifically examined the day-to-day input of family members into the care of people with dementia during an acute hospital admission. In this article, we present the results of analysis of interviews with 26 family members of people with dementia about their experiences of supporting an admission of a person with dementia to an acute hospital unit in New Zealand. For all family members, the desire to support the person with dementia during their admission was at the forefront and was their primary focus. The theme, ‘And so I took up residence’, exemplifies fully the experiences of all of the family member participants. This study provides evidence that family members are a resource that may be unrecognised, untapped and unsupported in the event of hospitalisation of people with dementia

Evaluating a train-the-trainer educational intervention to raise standards of care, within the nursing home sector in the United Kingdom

open access articleObjective: As a response to service needs and project development by the East Midlands Health Innovation Education Cluster, now the Health Education East Midlands, an education programme intervention was developed to raise the standards of clinical and non-clinical care, particularly within the nursing home sector. This paper discusses the development of the intervention based on the “train-the-trainer” model presenting data which highlights improved service quality and a reduction in NHS costs as a result of the training. Methods: The programme measured pre and post impact of the programme on the knowledge and confidence of the staff who took part and captured the impact of the overall training in terms of reported measures such as falls, urinary tract infections, referrals from nursing homes to an emergency department, and number of GP call outs to nursing homes. Results: Analysis revealed; an increase in knowledge and confidence of staff following training, an improvement in outcomes for all key measures including; falls, urinary tract infections, referrals to emergency departments, and number of GP callouts. The data also highlights cost reduction in all these areas based on cost estimates. Conclusions: There is evidence that the delivery of an education intervention in nursing homes, based on local/regional needs and adopting a 'train-the-trainer' approach can improve outcomes for residents and reduce costs for providers, including the NHS, in regard to reduced GP callouts and hospital admissions. It is important to have pre and post data collection measures in place to capture its impact on service quality and evaluate the cost effectiveness of programmes

‘This Adds Another Perspective’: Qualitative Descriptive Study Evaluating Simulation-Based Training for Health Care Assistants, to Enhance the Quality of Care in Nursing Homes

open access articleMuch of the UK’s ageing population lives in care homes, often with complex care needs including dementia. Optimal care requires strong clinical leadership, but opportunities for staff development in these settings are limited. Training using simulation can enable experiential learning in situ. In two nursing homes, Health Care Assistants (HCAs) received training in clinical communication skills (Situation-Background-Assessment-Recommendation Education through Technology and Simulation, SETS: group training with an actor simulating scenarios); and dementia (A Walk Through Dementia, AWTD: digital simulation, delivered one-to-one). In this qualitative descriptive study, we evaluated the potential of this training to enhance HCAs’ clinical leadership skills, through thematic analysis of 24 semi-structured interviews with HCAs (before/after training) and their managers and mentors. Themes were checked by both interviewers. HCAs benefitted from watching colleagues respond to SETS scenarios and reported greater confidence in communicating with registered healthcare professionals. Some found role-play participation challenging. AWTD sensitised HCAs to the experiences of residents with dementia, and those with limited dementia experience gained a fuller understanding of the disease’s effects. Staffing constraints affected participation in group training. Training using simulation is valuable in this setting, particularly when delivered flexibly. Further work is needed to explore its potential on a larger scale

Managing risk during care transitions when approaching end of life: a qualitative study of patients' and health care professionals' decision making

BACKGROUND: Increasing importance is being placed on the coordination of services at the end of life. AIM: To describe decision-making processes that influence transitions in care when approaching the end of life. DESIGN: Qualitative study using field observations and longitudinal semi-structured interviews. SETTING/PARTICIPANTS: Field observations were undertaken in three sites: a residential care home, a medical assessment unit and a general medical unit in New Zealand. The Supportive and Palliative Care Indicators Tool was used to identify participants with advanced and progressive illness. Patients and family members were interviewed on recruitment and 3-4 months later. Four weeks of fieldwork were conducted in each site. A total of 40 interviews were conducted: 29 initial interviews and 11 follow-up interviews. Thematic analysis was undertaken. FINDINGS: Managing risk was an important factor that influenced transitions in care. Patients and health care staff held different perspectives on how such risks were managed. At home, patients tolerated increasing risk and used specific support measures to manage often escalating health and social problems. In contrast, decisions about discharge in hospital were driven by hospital staff who were risk-adverse. Availability of community and carer services supported risk management while a perceived need for early discharge decision making in hospital and making 'safe' discharge options informed hospital discharge decisions. CONCLUSION: While managing risk is an important factor during care transitions, patients should be able to make choices on how to live with risk at the end of life. This requires reconsideration of transitional care and current discharge planning processes at the end of life

Prison Nurses’ Professional Identity

Recruitment and retention to the specialist field of Health and Justice Nursing, specifically prison nursing, is problematic in the UK. This article considers the background to the current situation in prison nursing and summarises some of the existing literature and research relating to this specialty to raise, for discussion and debate, issues which are pertinent to the concept of professional identity and professionalism. Role definition, resilience and burnout, and education within HJS nursing are identified in relation to the development of professional identity. If professional identity, role definition and education debates take place these are likely to impact problems of resilience, burnout, recruitment and retention. The article explores whether having a strong sense of professional identity could impact favourably on prison nurses’ ability to tap into their innate resilience and ameliorate the effects of emotional, personal and professional burnout. It could be that professional identity is the missing link to recruitment and retention

Developing a Clinical Academic Career Pathway in a Community and Mental Health NHS Trust

The file attached to this record is the author's final peer reviewed version. The Publisher's final version can be found by following the DOI link.Background: Despite growing evidence of the impact that clinical academic staff have on patient care and clinical practice, there are disproportionately low numbers of nurses, allied health professionals and other healthcare professionals in clinical academic joint roles, compared to their medical colleagues. Aim: To describe the initial development of a clinical academic career pathway for nurses, allied health professionals and other healthcare professionals in a community and mental health NHS Trust. Methods: Kotter’s Model for Change was used to expand opportunities and research culture across an NHS Trust. Results: A variety of capacity and capability initiatives at different academic levels were created to support clinical academic development and to complement those available externally. These opportunities were underpinned by a research and development strategy, senior leadership buy-in, manager and clinical staff support, and targeted organisation-wide communication. Conclusion: The ongoing development of innovative clinical academic opportunities in the Trust, alongside greater support for staff interested in pursuing clinical academic careers, has resulted in a growing number of individuals successful in developing as clinical academic. This has led to a growth in research culture in the organisation and a greater understanding of what clinical academic staff can bring to patient care, the clinical service, and the wider organisation

Evaluation of the theory-based Quality Improvement in Physical Therapy (QUIP) programme: a one-group, pre-test post-test pilot study

BACKGROUND: Guideline adherence in physical therapy is far from optimal, which has consequences for the effectiveness and efficiency of physical therapy care. Programmes to enhance guideline adherence have, so far, been relatively ineffective. We systematically developed a theory-based Quality Improvement in Physical Therapy (QUIP) programme aimed at the individual performance level (practicing physiotherapists; PTs) and the practice organization level (practice quality manager; PQM). The aim of the study was to pilot test the multilevel QUIP programme’s effectiveness and the fidelity, acceptability and feasibility of its implementation. METHODS: A one-group, pre-test, post-test pilot study (N = 8 practices; N = 32 PTs, 8 of whom were also PQMs) done between September and December 2009. Guideline adherence was measured using clinical vignettes that addressed 12 quality indicators reflecting the guidelines’ main recommendations. Determinants of adherence were measured using quantitative methods (questionnaires). Delivery of the programme and management changes were assessed using qualitative methods (observations, group interviews, and document analyses). Changes in adherence and determinants were tested in the paired samples T-tests and expressed in effect sizes (Cohen’s d). RESULTS: Overall adherence did not change (3.1%; p = .138). Adherence to three quality indicators improved (8%, 24%, 43%; .000 ≤ p ≤ .023). Adherence to one quality indicator decreased (−15.7%; p = .004). Scores on various determinants of individual performance improved and favourable changes at practice organizational level were observed. Improvements were associated with the programme’s multilevel approach, collective goal setting, and the application of self-regulation; unfavourable findings with programme deficits. The one-group pre-test post-test design limits the internal validity of the study, the self-selected sample its external validity. CONCLUSIONS: The QUIP programme has the potential to change physical therapy practice but needs considerable revision to induce the ongoing quality improvement process that is required to optimize overall guideline adherence. To assess its value, the programme needs to be tested in a randomized controlled trial

Advance Care Planning for older people: The influence of ethnicity, religiosity, spirituality and health literacy

The file attached to this record is the author's final peer reviewed version.Older people from cultural and ethnic minorities have low access to palliative or end-of-life care and there is poor uptake of Advance Care Planning by this group across a number of countries where Advance Care Planning is promoted. For many, religiosity, spirituality and health literacy are significant factors that influence how they make end-of-life decisions. Health literacy issues have been identified as one of the main reasons for a communication gaps between physicians and their patients in discussing end-of-life care, where poor health literacy, particularly specific difficulty with written and oral communication often limits their understanding of clinical terms such as diagnoses and prognoses. This then contributes to health inequalities given it impacts on their ability to use their moral agency to make appropriate decisions about end-of-life care and complete their Advance Care Plans. Currently, strategies to promote Advance Care Planning seem to overlook engagement with religious communities. Consequently, policy makers, nurses, medical professions, social workers and even educators continue to shape Advance Care Planning programmes within the context of a medical model. The ethical principle of justice is a useful approach to responding to inequities; and to promote older peoples’ ability to enact moral agency in making such decisions