Meeting patients' spiritual needs during end-of-life care: A qualitative study of nurses' and healthcare professionals' perceptions of spiritual care training.

AIMS AND OBJECTIVES: To explore nurses' and healthcare professionals' perceptions of spiritual care and the impact of spiritual care training on their clinical roles. BACKGROUND: Many nurses and healthcare professionals feel unprepared and lack confidence, competence and skills, to recognise, assess and address patients' spiritual issues. Patients with unmet spiritual needs are at increased risk of poorer psychological outcomes, diminished quality of life and reduced sense of spiritual peace. There are implications for patient care if nurses and healthcare professionals cannot attend to patients' spiritual needs. DESIGN: A qualitative methodology was adopted. METHODS: Recruitment was purposive. A total of 21 generalist and specialist nursing and healthcare professionals from North West and South West England, who undertook spiritual care training between 2015-2017, were recruited. Participants were required to be a minimum of 3 months posttraining. Digitally audio-recorded semistructured interviews lasting 11-40 min were undertaken in 2016-2017. Data were subjected to thematic analysis. Ethical committee approval was obtained. COREQ reporting guidelines were utilised. RESULTS: Two main themes were identified, recognising spirituality, with subthemes of what spirituality means and what matters, and supporting spiritual needs, with subthemes of recognition of spiritual distress, communication skills, not having the answers and going beyond the physical. CONCLUSIONS: Supporting patients as they approach the end of life needs a skilled workforce; acknowledging the importance of spiritual care and having skills to address it are central to delivery of best holistic care. RELEVANCE TO CLINICAL PRACTICE: Spiritual care is as important as physical care and supporting patients spiritually as they approach the end of life is vital. Appropriately trained, nurses and healthcare professionals are better able to assess, explore and meet patients' spiritual needs.

Supporting family carers providing end-of-life home care: a qualitative study on the impact of a hospice at home service.

AIMS AND OBJECTIVES: To explore bereaved family carers' perceptions and experiences of a hospice at home service. BACKGROUND: The increasing demand for the development of home-based end-of-life services is not confined to the western world; such services are also emerging in resource-poor countries where palliative care services are developing with limited inpatient facilities. Despite this growing trend, studies show a variety of interrelated factors, with an emphasis on the availability of informal carers and their ability to cope, which can influence whether terminally ill patients actually remain at home. A hospice at home service was developed to meet patients' and families' needs by providing individually tailored resources. DESIGN: A qualitative study. METHODS: Data were collected by semi-structured, digitally recorded interviews from 20 family carers who had experienced the service. Interviews were transcribed verbatim and a thematic approach adopted for analysis. RESULTS: All participants reported a personal positive impact of the service. Family carers commented the service provided a valued presence, they felt in good hands and importantly it helped in supporting normal life. CONCLUSIONS: The impact of an individualised, targeted, hospice at home service using dedicated, palliative care trained, staff, is perceived positively by family carers and importantly, supportive of those with additional caring or employment commitments. RELEVANCE TO CLINICAL PRACTICE: The emergence of hospice at home services has resulted in more options for patients and their families, when the increased amount of care a family member has to provide in these circumstances needs to be adequately supported, with the provision of a flexible service tailored to individual needs and delivered by appropriately trained staff.

Supporting home care for the dying: an evaluation of healthcare professionals' perspectives of an individually tailored hospice at home service.

AIMS AND OBJECTIVES: To explore health care professionals' perspective of hospice at home service that has different components, individually tailored to meet the needs of patients. BACKGROUND: Over 50% of adults diagnosed with a terminal illness and the majority of people who have cancer, prefer to be cared for and to die in their own home. Despite this, most deaths occur in hospital. Increasing the options available for patients, including their place of care and death is central to current UK policy initiatives. Hospice at home services aim to support patients to remain at home, yet there are wide variations in the design of services and delivery. A hospice at home service was developed to provide various components (accompanied transfer home, crisis intervention and hospice aides) that could be tailored to meet the individual needs of patients. DESIGN: An evaluation study. METHODS: Data were collected from 75 health care professionals. District nurses participated in one focus group (13) and 31 completed an electronic survey. Palliative care specialist nurses participated in a focus group (9). One hospital discharge co-ordinator and two general practitioners participated in semi-structured interviews and a further 19 general practitioners completed the electronic survey. RESULTS: Health care professionals reported the impact and value of each of the components of the service, as helping to support patients to remain at home, by individually tailoring care. They also positively reported that support for family carers appeared to enable them to continue coping, rapid access to the service was suggested to contribute to faster hospital discharges and the crisis intervention service was identified as helping patients remain in their own home, where they wanted to be. CONCLUSIONS: Health care professionals perceived that the additional individualised support provided by this service contributed to enabling patients to continue be cared for and to die at home in their place of choice. RELEVANCE TO CLINICAL PRACTICE: This service offers various components of a hospice at home service, enabling a tailor made package to meet individual and local area needs. Developing an individually tailored package of care appears to be able to meet specific needs.

Virtual learning environment ('Ivy Street') for palliative medicine education: student and facilitator evaluation.

AIM: The study aimed to evaluate student and facilitator perceptions regarding the novel use of a virtual learning environment (VLE) in the development and implementation of 'Ivy Street'. SAMPLE/METHODS: Healthcare professionals enrolled on the first palliative and end-of-life care masters level module and course facilitators were invited to participate in the study. Two online surveys were developed comprising five open-ended questions to gain both student (n=16) and facilitator (n=4) perceptions of Ivy Street. Data were analysed thematically. FINDINGS: The key theme to emerge was the 'Positive Perceptions of Ivy Street'. A second sub theme 'Critical Feedback of Ivy Street' focused on some initial technical issues. Respondents perceived the use of Ivy Street to be enjoyable, enabling and promoting peer discussion, while also having a high impact on student engagement. Respondents commented how Ivy Street removed concerns regarding confidentiality when discussing patient cases through utilisation of standardised Ivy Street characters. CONCLUSION: The novel use of a VLE through developing characters, a story and vignettes is considered to be an effective and engaging method of learning for healthcare professionals enrolled on a palliative and end-of-life care module.

Effect of Short-term Integrated Palliative Care on Patient-Reported Outcomes Among Patients Severely Affected With Long-term Neurological Conditions: A Randomized Clinical Trial.

Importance: Palliative care has shown benefits in reducing symptom intensity and quality of life in patients with advanced cancer. However, high-quality evidence to support palliative care policy and service developments for patients with long-term neurological conditions (LTNCs) is lacking. Objective: To determine the effectiveness of a short-term integrated palliative care (SIPC) intervention for people with LTNCs. Design, Setting, and Participants: Multicenter, phase 3, randomized clinical trial conducted from April 1, 2015, to November 30, 2017, with a last follow-up date of May 31, 2018, in 7 UK hospitals with both neurology and palliative care services. A total of 535 patients with LTNC were assessed for eligibility and 350 were randomized. Inclusion criteria were patients 18 years or older with any advanced stage of multiple sclerosis, motor neuron disease, idiopathic Parkinson disease multiple system atrophy, or progressive supranuclear palsy. Data were analyzed from November 2018 to March 2019. Interventions: Patients were randomized 1:1 using minimization method to receive SIPC (intervention, n = 176) or standard care (control, n = 174). Main Outcomes and Measures: Primary outcome was change in 8 key palliative care symptoms from baseline to 12-weeks, measured by the Integrated Palliative care Outcome Scale for neurological conditions. Secondary outcomes included change in the burden of other symptoms, health-related quality of life, caregiver burden, and costs. Data were collected and analyzed blindly by intention to treat. Results: A total of 350 patients (mean [SD] age 67 [12] years; years since diagnosis, 12 [range, 0-56]; 51% men; 49% requiring considerable assistance) with an advanced stage of LTNC were recruited, along with informal caregivers (n = 229). There were no between-group differences in primary outcome (effect size, -0.16; 95% CI, -0.37 to 0.05), any other patient-reported outcomes, adverse events, or survival. Although there was more symptom reduction in the SIPC group in relation to mean change in primary outcome, the difference between the groups was not statistically significant (-0.78; 95% CI, -1.29 to -0.26 vs -0.28; 95% CI, -0.82 to 0.26; P = .14). There was a decrease in mean health and social care costs from baseline to 12 weeks -$1367 (95% CI, -$2450 to -$282) in the SIPC group and -653 (95% CI, -$1839 to -$532) in the control group, but this difference was not statistically significant (P = .12). SIPC was perceived by patients and caregivers as building resilience, attending to function and deficits, and enabling caregivers. Conclusions and Relevance: In this study, SIPC was not statistically significantly different from standard care for the patient-reported outcomes. However, SIPC was associated with lower cost, and in qualitative analysis was well-received by patients and caregivers, and there were no safety concerns. Further research is warranted. Trial Registration: isrctn.org Identifier: ISRCTN18337380.

Patient characteristics associated with a poor response to non-surgical multidisciplinary management of knee osteoarthritis: a multisite prospective longitudinal study in an advanced practice physiotherapist-led tertiary service.

OBJECTIVES: To explore patient characteristics recorded at the initial consultation associated with a poor response to non-surgical multidisciplinary management of knee osteoarthritis (KOA) in tertiary care. DESIGN: Prospective multisite longitudinal study. SETTING: Advanced practice physiotherapist-led multidisciplinary orthopaedic service within eight tertiary hospitals. PARTICIPANTS: 238 patients with KOA. PRIMARY AND SECONDARY OUTCOME MEASURES: Standardised measures were recorded in all patients prior to them receiving non-surgical multidisciplinary management in a tertiary hospital service across multiple sites. These measures were examined for their relationship with a poor response to management 6 months after the initial consultation using a 15-point Global Rating of Change measure (poor response (scores -7 to +1)/positive response (scores+2 to+7)). Generalised linear models with binomial family and logit link were used to examine which patient characteristics yielded the strongest relationship with a poor response to management as estimated by the OR (95% CI). RESULTS: Overall, 114 out of 238 (47.9%) participants recorded a poor response. The odds of a poor response decreased with higher patient expectations of benefit (OR 0.74 (0.63 to 0.87) per 1/10 point score increase) and higher self-reported knee function (OR 0.67 (0.51 to 0.89) per 10/100 point score increase) (p<0.01). The odds of a poor response increased with a greater degree of varus frontal knee alignment (OR 1.35 (1.03 to 1.78) per 5° increase in varus angle) and a severe (compared with mild) radiological rating of medial compartment degenerative change (OR 3.11 (1.04 to 9.3)) (p<0.05). CONCLUSIONS: These characteristics may need to be considered in patients presenting for non-surgical multidisciplinary management of KOA in tertiary care. Measurement of these patient characteristics may potentially better inform patient-centred management and flag the need for judicious monitoring of outcome for some patients to avoid unproductive care.

Integrating palliative care into neurology services: what do the professionals say?

OBJECTIVES: Evaluations of new services for palliative care in non-cancer conditions are few. OPTCARE Neuro is a multicentre trial evaluating the effectiveness of short-term integrated palliative care (SIPC) for progressive long-term neurological conditions. Here, we present survey results describing the current levels of collaboration between neurology and palliative care services and exploring the views of professionals towards the new SIPC service. METHODS: Neurology and palliative care teams from six UK trial sites (London, Nottingham, Liverpool, Cardiff, Brighton and Chertsey) were approached via email to complete an online survey. The survey was launched in July 2015 and consisted of multiple choice or open comment questions with responses collected using online forms. RESULTS: 33 neurology and 26 palliative care professionals responded. Collaborations between the two specialties were reported as being 'good/excellent' by 36% of neurology and by 58% of palliative care professionals. However, nearly half (45%) of neurology compared with only 12% of palliative care professionals rated current levels as being 'poor/none'. Both professional groups felt that the new SIPC service would influence future collaborations for the better. However, they identified a number of barriers for the new SIPC service such as resources and clinician awareness. CONCLUSIONS: Our results demonstrate the opportunity to increase collaboration between neurology and palliative care services for people with progressive neurological conditions, and the acceptability of SIPC as a model to support this. TRIAL REGISTRATION NUMBER: ISRCTN18337380; Pre-results.

An introduction to the Micrel Micropump MP Daily portable syringe driver.

In this article the author describes the Micrel Micropump MP Daily (MP Daily) portable syringe driver. This follows the author's experience of a 4-month pilot of the device by an inpatient palliative care unit. Portable syringe drivers are commonly used to deliver continuous subcutaneous infusions in palliative care situations. Those in current use are not without problems and serious adverse events have occasionally been reported, mainly resulting from confusion between models. The MP Daily syringe driver addresses some of these issues while remaining small, lightweight and inexpensive, with a long battery life and fitting into the pocket of a shirt of pyjama jacket. Improvements over current models include an on/off button, the absence of facilities to set a zero rate or change the rate once the syringe driver is running, and the absence of a boost button. In addition, there are improved alarms, a message display system and a configuration menu. Although confusion remains a problem, and the ideal has not yet been reached, the MP Daily goes some considerable way towards reducing risks and opportunities for human error.

Enhancing communication with distressed patients, families and colleagues: the value of the Simple Skills Secrets model of communication for the nursing and healthcare workforce.

BACKGROUND: Good communication skills in healthcare professionals are acknowledged as a core competency. The consequences of poor communication are well-recognised with far reaching costs including; reduced treatment compliance, higher psychological morbidity, incorrect or delayed diagnoses, and increased complaints. The Simple Skills Secrets is a visual, easily memorised, model of communication for healthcare staff to respond to the distress or unanswerable questions of patients, families and colleagues. OBJECTIVES: To explore the impact of the Simple Skills Secrets model of communication training on the general healthcare workforce. DESIGN AND METHODS: An evaluation methodology encompassing a quantitative pre- and post-course testing of confidence and willingness to have conversations with distressed patients, carers and colleagues and qualitative semi-structured telephone interviews with participants 6-8 weeks post course. PARTICIPANTS: During the evaluation, 153 staff undertook the training of which 149 completed the pre- and post-training questionnaire. A purposive sampling approach was adopted for the follow up qualitative interviews and 14 agreed to participate. RESULTS: There is a statistically significant improvement in both willingness and confidence for all categories; (overall confidence score, t(148)=-15.607, p=<0.05 overall willingness score, t(148)=-10.878, p=<0.05) with the greatest improvement in confidence in communicating with carers (pre-course mean 6.171 to post course mean 8.171). There is no statistical significant difference between the registered and support staff. Several themes were obtained from the qualitative data, including: a method of communicating differently, a structured approach, thinking differently and additional skills. The value of the model in clinical practice was reported. CONCLUSION: This model can be suggested as increasing the confidence of staff, in dealing with a myriad of situations which, if handled appropriately can lead to increased patient and carers' satisfaction. Empowering staff appears to have increased their willingness to undertake these conversations, which could lead to earlier intervention and minimise distress.