Strengthening primary health care teams with palliative care leaders: protocol for a cluster randomized clinical trial.

BACKGROUND: The objective of the Balearic Islands Palliative Care (PC) Program is to improve the quality of PC through a shared model consisting of primary health care professionals, home-based PC teams, and PC units in hospitals. According to the World Health Organization (WHO), patients with advanced cancer and other terminal diseases benefit from early identification and proactive PC. We will evaluate the effectiveness of an intervention in which a PC leader is established in the primary health care center, and assess the effect of this intervention on the early identification of patients in need of PC, the efficient use of health care services, and direct health care costs. METHODS: Design: A two-arm cluster randomized clinical trial of 30 Primary Health Care Centers (PHCC) in Mallorca (Spain), in which each center was randomized to an intervention arm or a usual care arm. We expect that the number of patients identified as suitable for PC (including non-oncological PC) is at least 5% greater in the intervention arm. SAMPLE SIZE: A total of 4640 deceased patients. Outcomes will be assessed by a blinded external review of the electronic records. INTERVENTIONS: General practitioners (GPs) and nurse leaders in PC for each PHCC will be appointed. These leaders will help promote PC training of colleagues, improve symptom management and psychological support of patients, and evaluate the complexity of individual cases so that these cases receive assistance from PC home-based teams. MEASUREMENTS: Early identification (>90 days before death), evaluation of case complexity, level of case complexity (with referral to a home-based PC team), use and cost of hospital and primary care services, and quality of life during the last month of life (≥2 emergency room visits, ≥2 hospital admissions, ≥14 days of hospitalization). DISCUSION: PC leaders in primary care teams will improve the early identification of patients eligible for PC. This initiative could improve the quality of end-of-life care and utilization of hospital resources. TRIAL REGISTRATION: ISRCTN Registry identifier: ISRCTN92479122 . Retrospectively registered on 28 February 2017.

Spiritual Care[Givers] Competence in Palliative Care: A Scoping Review.

To deliver spiritual care, professionals must be skilled in physical, mental, social, and spiritual care. Spiritual care competence includes knowledge, behaviors, attitudes, and skills that enable successful or efficient care. This review aims to identify the scope of competence and the specific skills, knowledge, and attitudes used in providing spiritual care to people needing palliative care, and the main challenges and facilitators. A scoping review was developed using the Joanna Briggs Institute methodology. Six databases (Web of Science; MEDLINE/Pubmed; Scopus; CINAHL; MedicLatina and SciELO) were searched in September 2023, with an update in January 2024. The resulting 30 articles were analyzed using a content analysis approach. Information was categorized into three domains: cognitive, affective, and functional (based on three personal resources: intrapersonal, interpersonal, and transpersonal). Palliative care professionals face a lack of training and insufficient preparation to deliver spiritual care. Spiritual care competence depends on professional spiritual development and experience, spiritual intelligence (cognitive), spiritual humility (affective), and having a critical and reflexive mind (functional). In the future, palliative care should seek to improve competent spiritual care. This review could help clarify the real configuration of competent spiritual care and lead to improvements in a professional's empowerment when delivering effective spiritual care to patients and families.

SPACEE Protocol: "Spiritual Care Competence" in PAlliative Care Education and PracticE: Mixed-Methods Research in the Development of Iberian Guidelines.

Spiritual care requires understanding the spiritual experiences of patients and recognizing their resources and needs. Therefore, educators and practitioners should develop their knowledge and understanding in this regard. Spiritual care helps people overcome their anxieties, worries, and suffering; reduces stress; promotes healing; and encourages patients to find inner peace. To provide comprehensive and appropriate care while upholding human/ethical virtues, the spiritual dimension must be a priority. We aim to develop spiritual care competence guidelines for Palliative Care (PC) education and practice in Portugal and Spain. The study detailed in this protocol paper will include three phases. In phase I, the phenomenon will be characterized and divided into two tasks: (1) a concept analysis of "spiritual care competence"; and (2) a systematic review of interventions or strategies used to integrate spiritual care in PC education and practice. Phase II will entail a sequential explanatory approach (online survey and qualitative interviews) to deepen understanding of the perceptions and experiences of educators, practitioners, and patients/family carers regarding spiritual care in PC education and practice and generate ideas for the next steps. Phase III will comprise a multi-phased, consensus-based approach to identify priority areas of need as decided by a group of experts. Results will be used to produce guidelines for integrating spirituality and spiritual care competence within PC education and practice and synthesized in a white book for PC professionals. The value of this improved examination of spiritual care competence will ultimately depend on whether it can inform the development and implementation of tailored educational and PC services. The project will promote the 'spiritual care' imperative, helping practitioners and patients/family carers in their preparedness for End-of-Life care, as well as improving curricular practices in this domain.

A Brief Measure for the Assessment of Competence in Coping With Death: The Coping With Death Scale Short Version.

CONTEXT: The coping with death competence is of great importance for palliative care professionals, who face daily exposure to death. It can keep them from suffering compassion fatigue and burnout, thus enhancing the quality of the care provided. Despite its relevance, there are only two measures of professionals' ability to cope with death. Specifically, the Coping with Death Scale (CDS) has repeatedly shown psychometric problems with some of its items. OBJECTIVE: The aim of this study was to develop and validate a short version of the CDS. METHODS: Nine items from the original CDS were chosen for the short version. Two cross-sectional surveys were conducted in Spanish (N = 385) and Argentinian (N = 273) palliative care professionals. The CDS and the Professional Quality of Life Scale were used in this study. Statistical analyses included two confirmatory factor analyses (CFAs), followed by a standard measurement invariance routine. Reliability estimates and evidence of validity based on relations with other measures were also gathered. RESULTS: CFA models had excellent fit in both the Spanish (χ2(27) = 107.043, P < 0.001; Comparative Fit Index [CFI] = 0.978; Tucker-Lewis Index [TLI] = 0.970; Root Mean Square Error of Approximation [RMSEA] = 0.093 [0.075, 0.112]; Standardized Root Mean Square Residual = 0.030) and Argentinian (χ2(27) = 102.982, P < 0.001; CFI = 0.963; TLI = 0.950; RMSEA = 0.106 [0.085, 0.128]) samples. A standard measurement invariance routine was carried out. The most parsimonious model (χ2(117) = 191.738, P < 0.001; CFI = 0.987; TLI = 0.992; RMSEA = 0.046 [0.034, 0.058]; Standardized Root Mean Square Residual = 0.043) offered evidence of invariance across countries, with no latent mean differences. Evidence of reliability and evidence of validity based on relations with other measures were also appropriate. CONCLUSION: Results indicated the psychometric boundaries of the short version of the CDS.

Compassion Satisfaction, Compassion Fatigue, and Burnout in Spain and Brazil: ProQOL Validation and Cross-cultural Diagnosis.

CONTEXT: Palliative care professionals' quality of life has emerged as a growing issue of interest in health care literature, centered on concerns about professionals' compassion within a context of work characterized by pain and death. OBJECTIVES: The aim of this study was threefold: 1) to study the psychometric properties of both the Spanish and the Portuguese versions of the ProQOL scale, by means of confirmatory factor analyses; 2) to offer a diagnosis of compassion satisfaction and compassion fatigue levels of Spanish and Brazilian palliative care professionals; and 3) to compare levels in ProQOL between countries. METHODS: Two surveys with a cross-sectional design were carried out; 161 Brazilian palliative care professionals and 385 Spanish participated in this study. RESULTS: Confirmatory factor analysis for both the Spanish and the Portuguese versions showed an adequate fit. Reliability estimates were also adequate, with problems with the burnout dimension. Spanish and Brazilian palliative care professionals showed high levels of compassion satisfaction (specially, for the Brazilian samples), medium levels of secondary traumatic stress, and low levels of burnout. Finally, statistically significant differences in Spanish and Brazilian levels of compassion satisfaction and secondary traumatic stress were found, but not in burnout. CONCLUSION: The ProQOL shows psychometric goodness in its Spanish and Portuguese versions, although some items should be revised. The ProQOL is also useful for diagnosis and is sensitive enough to distinguish nuances as that found between Brazilian and Spanish professionals.

Evaluation tools for spiritual support in end of life care: increasing evidence for their clinical application.

PURPOSE OF REVIEW: To summarize current evidence on evaluation tools for spiritual care, paying special attention to recent validations and new instruments, systematic reviews, recent consensus on spiritual care and its measurement, plus other emergent topics. RECENT FINDINGS: The systematic review resulted in 45 identified studies, 14 of which were considered: five works addressed the need for development and validation of spiritual tools; three studies reviewed tools for spirituality assessment, interventions, or related concepts; three more covered the efforts to define guidelines and priorities for spiritual care and its measurement. Other topics such as pediatric spiritual care, the use of new technologies, or nationwide surveys, also arose. SUMMARY: Recent contributions outline usability traits such as to shorten scales and measurement protocols for maximum respect of patients' quality of life. Other works addressed complicated grief or satisfaction with attention to spiritual care, transcending the patients, family and professionals' focus in on a sort of combined perspective. Further attention to culturally based specific models supporting questionnaires, a deeper understanding of quality of the spiritual care, both for patients and families, or further research on the relation between spiritual care and life span should be welcomed.

Validation of a New Instrument for Self-care in Spanish Palliative Care Professionals Nationwide.

Self-care is a cornerstone issue for those who deal with stressful events, as it is the case of palliative care professionals. It has been related to awareness, coping with death and quality of life, among others, but no measurement instruments have been used in palliative care professionals. This research presents and validates a brief new measure with clinical and psychometric good properties, called Professional Self-Care Scale (PSCS). The PSCS assesses professionals' self-care in three areas: physical self-care, inner self-care, and social self-care. Data come from a cross-sectional survey in a sample of 385 professionals of palliative care. The Mindful Attention Awareness Scale, the Coping with Death Scale, and the Professional's Quality of Life measure were also used. Results of the CFA showed adequate fit (χ2(24, N = 385) = 140.66, p < .01; CFI = .91; GFI = .93; SRMR = .09; and RMSEA = .10). Evidence pointed better reliability indices for the 3-item physical and inner factors of self-care than for the social dimension (Rho and GLB of .64, .90, and .57, respectively). Evidence regarding validity was consistent with previous literature. When levels of self-care were examined, women showed higher levels of inner and social self-care (F(3, 371) = 3.19, p = .02, η2 = .03, as also did psychologists when compared to doctors and nurses (F(9, 1074) = 2.00, p = .04, η2 = .02. The PSCS has shown adequate psychometric properties, and thus it could be used as diagnostic instrument when studying professionals' health.

Palliative Care Professionals' Inner Life: Exploring the Relationships Among Awareness, Self-Care, and Compassion Satisfaction and Fatigue, Burnout, and Coping With Death.

CONTEXT: Professionals working in the landscape of death and dying frequently are exposed to existential issues, psychological challenges, and emotional distress associated with care at the end of life. Identifying factors that help professionals cope with frequent exposure to issues related to mortality could enhance palliative care providers' and patients' quality of life. OBJECTIVES: To improve our understanding of the factors associated with professionals' inner life, through the assessment of an adapted version of Kearney and Kearney's awareness model of self-care. The main assumptions of the study were that competence in coping with death and awareness would be positively related to compassion satisfaction and negatively to compassion fatigue and burnout; moreover, participating in a specific training program aimed at facing suffering and death, and self-care would positively predict coping with death. METHODS: A cross-sectional online survey of Spanish palliative care professionals was conducted through the member e-mail list of the Spanish Society of Palliative Care. A total of 387 professionals completed the survey, which included demographic data, and personal and professional scales on the mentioned constructs. RESULTS: Data fit reasonably well with the estimated model. Whereas the hypothesis relating spiritual training to coping with death was not supported by the data, all other aspects of the hypotheses were supported, namely self-care and awareness positively predicted professionals' competence in coping with death, and this, together with awareness, positively predicted compassion satisfaction and negatively predict compassion fatigue and burnout. CONCLUSION: The awareness-based model of self-care was successfully tested in a multidisciplinary sample of Spanish palliative care professionals. This research applies a quantitative evaluation of the model, providing evidence of a constellation of key variables for health professionals' quality of life, such as specific training, self-care, awareness and coping with death competency.

Associations between sociodemographic and lifestyle factors and dietary quality among adolescents in Palma de Mallorca.

OBJECTIVE: We assessed associations between sociodemographic and lifestyle factors and dietary quality among adolescents. METHODS: Subjects were 445 adolescents (171 boys, 274 girls; 14 to 18 y old) selected from the Palma de Mallorca (Balearic Islands, Spain) school census (96% participation) using two-stage probability sampling. The study protocol included dietary intake by means of a validated semiquantitative food-frequency questionnaire; sociodemographic factors of sex, maternal level of education, parental occupational status, and maternal region of origin; physical activity; and body weight and height measurements. Body mass index was calculated and energy intake expressed as multiples of basal metabolic rate. RESULTS: Mean daily energy intakes were 12.9 MJ for boys and 12.0 MJ for girls. Boys showed a higher percentage of energy from carbohydrates but a lower percentage from proteins and fat than did girls (44.9 versus 41.6, 18.8 versus 19.8, and 36.3 versus 38.5, respectively). Dietary fiber intake was within the recommended levels. Mineral and vitamin intakes generally met their estimated needs, except for vitamins A and D, which covered less than two-thirds of the recommended intake. Maternal educational level was positively correlated with dietary mineral and vitamin intakes. A positive relation between physical activity and dietary intakes of carbohydrate and of mineral and vitamin was found. CONCLUSIONS: Maternal level of education and physical activity are associated to the quality of diet among adolescents in Palma de Mallorca.

Development and validation of a new tool for the assessment and spiritual care of palliative care patients.

CONTEXT: Spiritual assessment tools and interventions based on holistic approaches are needed to promote healing. Such tools must be adapted to the wide cultural backgrounds of contemporary Western society. OBJECTIVES: To develop and validate a new brief measure, simultaneously featuring clinical applicability and adequate psychometric properties. The tool uses six initial questions to establish a climate of trust with patients before they complete an eight-item, five-point Likert scale. The questionnaire is based on a model of spirituality generated by the Spanish Society of Palliative Care (SECPAL) Task Force on Spiritual Care (Grupo de Espiritualidad de la SECPAL), which aims to recognize, share, and assess the spiritual resources and needs of palliative care patients. METHODS: Multidisciplinary professionals from 15 palliative care teams across Spain interviewed 108 patients using the Grupo de Espiritualidad de la SECPAL questionnaire. Confirmatory factor analysis techniques were used to study the new tool factor structure and reliability. Additionally, concurrent criterion validity coefficients were estimated considering spiritual well-being, anxiety, depression, resilience, and symptoms. Descriptive statistics on questionnaire applicability were reported. RESULTS: Analyses supported a three-factor structure (intrapersonal, interpersonal, transpersonal) with an underlying second-order factor representing a spirituality construct. Adequate reliability results and evidence for construct validity were obtained. CONCLUSION: The new questionnaire, based on empirical research and bedside experience, showed good psychometric properties and clinical applicability.

Evaluación psicométrica en profesionales de enfermería de cuidados paliativos / Psychometric Evaluation of Nursing Professionals Involved in Palliative Care / Avaliação psicométrica em profissionais de enfermagem de cuidados paliativos

RESUMEN Objetivo: validar las escalas de Bienestar Psicológico de Ryff en enfermería y relacionarlas con variables clave en calidad de vida laboral. Materiales y métodos: participaron por encuesta electrónica, autoadministrada anónima, 433 profesionales, 33,1% de ellos profesionales de enfermería (n = 123) en quienes se realizó el estudio. Además de los datos sociodemográficos, se recogió información sobre bienestar psicológico, atención consciente, afrontamiento de la muerte y calidad de vida. La validez de constructo fue evaluada con análisis factorial confirmatorio. Se estimó fiabilidad y se recogieron evidencias de validez externa. Resultados: el modelo mostró ajuste adecuado: X2(362) = 438,59 (p = 0,01), CFI = 0,98, RMSEA = 0,05 (0,03-0,06) y fiabilidad adecuada para todas las dimensiones, excepto autonomía. Las dimensiones de bienestar se relacionaron moderada y positivamente con autoconciencia, afrontamiento ante la muerte y satisfacción por compasión, y negativamente con fatiga por compasión y burnout. Se destacan las relaciones entre dominio del entorno y burnout (-0,54) y propósito en la vida con satisfacción (0,54) y con afrontamiento de la muerte (0,50). Conclusiones: los resultados apoyan el uso de estas escalas en enfermería, pues muestran adecuada fiabilidad y validez, y varias de ellas explican hasta una cuarta parte de indicadores relevantes en salud laboral como burnout o satisfacción vital.

ABSTRACT Objective: The study was intended to validate Ryff's psychological well-being scales in nursing and to relate them to key variables in the quality of life at work. Materials and method: Four hundred thirty-three (433) professionals took part through an anonymous, self-administered electronic survey; 33.1% were nursing professionals (n = 123) and the authors focused on them. In addition to sociodemographic data, information was collected on psychological well-being, mindfulness, coping with death, and quality of life. Construct validity was evaluated through confirmatory factor analysis. Reliability was estimated and evidence of external validity was collected. Results: The model showed adequate adjustment: X2(362) = 438.59 (p = 0.01), CFI = 0.98, RMSEA = 0.05 [0.03-0.06] and adequate reliability for all the dimensions except autonomy. The dimensions of well-being were moderately and positively with self-awareness, coping with death, and satisfaction from compassion, and negatively with fatigue from compassion and burnout. The association between dominance of the environment and burnout (-0.54), purpose in life and satisfaction (0.54) and coping with death (0.50) stood out. Conclusions: The results support the use of these scales in nursing, since they demonstrate adequate reliability and validity. In fact, several of them explain up to a quarter of the relevant indicators in occupational health, such as burnout or satisfaction with life.

RESUMO Objetivos: validar as escalas de Bem-estar Psicológico de Ryff em enfermagem e relacioná-las com variáveis fundamentais em qualidade de vida no trabalho. Materiais e método: participaram por enquete eletrônica autoadministrada anônima 433 profissionais - 33,1 % profissionais de enfermagem (n=123), nos quais nos focamos. Além de informação sociodemográfica, coletou-se informação sobre bem-estar psicológico, atenção consciente, enfrentamento da morte e qualidade de vida. A validade de constructo foi avaliada com análise fatorial confirmatória. Estimou confiabilidade e coletaram-se evidências de validade externa. Resultados: o modelo mostrou ajuste adequado: X2(362) = 438,59 (p = 0,01), CFI = 0,98, RMSEA = 0,05 [0,03-0,06] e confiabilidade adequada para todas as dimensões, exceto autonomia. As dimensões do bem-estar foram relacionadas moderada e positivamente com autoconsciência, enfretamento da morte e satisfação por compaixão, e negativamente com fatiga por compaixão e burnout. Destacam-se as relações entre domínio do ambiente e burnout (-0,54), propósito na vida com satisfação (0,54) e com enfrentamento da morte (0,50). Conclusões: os resultados apoiam o uso dessas escalas em enfermagem, pois mostram adequada confiabilidade e validade, e várias delas explicam até um quarto de indicadores relevantes em saúde do trabalho, como burnout ou satisfação vital.

Quality of life for oncology patients during the terminal period. Validation of the HRCA-QL index.

AIM: The evolution of performance status, disability, and quality of life (QL) according to the Hebrew Rehabilitation Center for Aged QL (HRCA-QL) index for cancer patients through their terminal period is described. The assessment of HRCA-QL validity and reliability is also described. DESIGN: A total of 200 cancer patients were followed up from the onset of their "terminal phase" until they died. Information on symptoms, performance, disability and QL were collected by patient's oncologists in hospital and by their family practitioners and community nurses when the patient was at home. Health measures were: the HRCA-QL index, Karnofsky performance status (KPS) and the Independence in Activities of Daily Living (IADL) index. RESULTS: The three indices were acceptable for a fair number of patients at the start of the terminal phase. Almost two-thirds had a KPS > or =60. With respect to the IADL index, the patients were independent in five of the six functions, with 80% having a HRCA-QL equal to or greater than 4. The median duration of the terminal period was 59 days. All three indices declined progressively, with marked deterioration in the last 2 weeks. The HRCA-QL index was highly correlated with KPS and the IADL index, had good internal consistency and showed an acceptable test-retest and inter-rater reliability. The HRCA-QL index was reactive to clinical changes. CONCLUSIONS: All three scales confirmed that terminal patients experience a progressive loss of performance, increase in dependence and deterioration of QL as they approach the end of life. Based in these results, we consider the HTCA-QL index valid for use in terminal cancer patients.