Factors related to implementation of an interprofessional communication concept in thoracic oncology: a mixed-methods study.

BACKGROUND: An innovative patient-centred interprofessional communication concept with advanced lung cancer patients (Heidelberg Milestone Communication Approach, MCA) has been developed and implemented. Role changes and interprofessional communication are challenging in a busy outpatient oncology service. The aim of the study was to present attitudes to interprofessional collaboration of professions in thoracic oncology during the implementation of MCA and to explore factors and experiences healthcare team members associate with its implementation. METHODS: In a longitudinal study, 3 of the 4 subscales of the validated German translation of the University of the West of England Interprofessional Questionnaire (UWE-IP-D) were collected prior to implementation of MCA (t0) with follow-up data collections at 4 months (t1), 10 months (t2) and 17 months (t3). Descriptive analysis included calculating subscale sum scores and categorizing each subscale into positive, neutral and negative attitudes. Interviews and focus groups on implementation and interprofessional collaboration in the context of MCA were conducted with healthcare staff. The topics were analysed deductively, guided by the Professional Interactions factor of the Tailored Implementation for Chronic Diseases (TICD) framework. RESULTS: The survey with 87 staff (44 nurses, 13 physicians, 12 psycho-social staff, 7 therapists, and 11 others) participating at least once found heterogeneous attitudes. 'Communication and Teamwork' and 'Interprofessional Relationships' were characterized by primarily positive attitudes. Neutral attitudes to 'Interprofessional Interaction' were indicated by the majority of respondents. There were no differences between collection times. Fifteen staff members participated in the interviews and focus groups. The main interprofessional interaction factors associated with implementation concerned the knowledge of the MCA and the impact of the intervention on team roles, on information sharing and on transfer processes between wards. Adaptive processes led to a shift in the perception of responsibilities and interprofessional collaboration. CONCLUSIONS: Positive experiences and potential shortfalls in the implementation were observed. Future introductions of interprofessional communication concepts require further activities which should address the attitudes of healthcare professionals towards interprofessional care. TRIAL REGISTRATION: DRKS00013469 / Date of registration: 22/12/2017.

Effects of an Interprofessional Communication Approach on Support Needs, Quality of Life, and Mood of Patients with Advanced Lung Cancer: A Randomized Trial.

BACKGROUND: To address the support needs of newly diagnosed patients with lung cancer with limited prognosis, the Milestone Communication Approach (MCA) was developed and implemented. The main elements of the MCA are situation-specific conversations along the disease trajectory conducted by an interprofessional tandem of physician and nurse. The aim of the study was to evaluate the effects of MCA on addressing support needs, quality of life, and mood as compared with standard oncological care. PATIENTS AND METHODS: A randomized trial was conducted with baseline assessment and follow-up assessments at 3, 6, and 9 months in outpatients with newly diagnosed lung cancer stage IV at a German thoracic oncology hospital. The primary outcome was the Health System and Information Needs subscale of the Short Form Supportive Care Needs Survey (SCNS-SF34-G) at 3-month follow-up. Secondary outcomes included the other subscales of the SCNS-SF34-G, the Schedule for the Evaluation of Individual Quality of Life, the Functional Assessment of Cancer Therapy lung module, the Patient Health Questionnaire for Depression and Anxiety, and the Distress Thermometer. RESULTS: At baseline, 174 patients were randomized, of whom 102 patients (MCA: n = 52; standard care: n = 50) provided data at 3-month follow-up. Patients of the MCA group reported lower information needs at 3-month follow-up (mean ± SD, 33.4 ± 27.5; standard care, 43.1 ± 29.9; p = .033). No effects were found for secondary outcomes. CONCLUSION: MCA lowered patient-reported information needs but did not have other effects. MCA contributed to tailored communication because an adequate level of information and orientation set the basis for patient-centered care. IMPLICATIONS FOR PRACTICE: By addressing relevant issues at predefined times, the Milestone Communication Approach provides individual patient-centered care facilitating the timely integration of palliative care for patients with a limited prognosis. The needs of patients with lung cancer must be assessed and addressed throughout the disease trajectory. Although specific topics may be relevant for all patients, such as information about the disease and associated health care, situations of individual patients and their families must be considered. Additionally, using the short form of the Supportive Care Needs Survey in clinical practice to identify patients' problems might support individually targeted communication and preference-sensitive care.

Consideration of sense of coherence in a structured communication approach with stage IV lung cancer patients and their informal caregivers: a qualitative interview study.

OBJECTIVE: Salutogenetic aspects are valuable for consideration in patient-centred care of advanced oncological diseases with a limited life expectancy. The Milestone Communication Approach (MCA), involving physician-nurse tandems, addresses specific challenges and needs over the disease trajectory of patients with stage IV lung cancer and their informal caregivers. This study aims to explore patients' and informal caregivers' salutogenetic experiences with the MCA concept. METHODS: This qualitative study used face-to-face semi-structured interviews with patients and informal caregivers. All generated data were audio-recorded, pseudonymised and transcribed verbatim. Data were structured using Qualitative Content Analysis. The material was coded deductively into themes related to the components of sense of coherence (Aaron Antonovsky) and emerging sub-themes. All data was managed and organised in MAXQDA. RESULTS: In 25 interviews, sense of coherence was referred to with all three components: "Comprehensibility" was supported by information conveyed suitably for the patients; "meaningfulness" was addressed as accepting the situation; and "manageability" led to advance care planning the patients were comfortable with. Patients and informal caregivers experienced the interprofessional tandem as an added value for patient care. CONCLUSIONS: Participants appreciate the MCA in its support for coping with a life-limiting disease. Considering salutogenetic aspects facilitates prognostic awareness and advance care planning. Nevertheless, individual needs of patients and informal caregivers require an individualised application of the MCA.

Implementation of the milestones communication approach for patients with limited prognosis: evaluation of intervention fidelity.

BACKGROUND: Despite improvements in diagnostics and therapy, the majority of lung tumours are diagnosed at advanced stage IV with a poor prognosis. Due to the nature of an incurable disease, patients need to engage in shared decision making on advance care planning. To implement this in clinical practice, effective communication between patients, caregivers and healthcare professionals is essential. The Heidelberg Milestones Communication Approach (MCA) is delivered by a specifically trained interprofessional tandem and consists of four milestone conversations (MCs) at pivotal times in the disease trajectory. MC 1 (Diagnosis): i.e. prognosis; MC 2 (Stable disease): i.e. prognostic awareness; MC 3 (Progression): i.e. reassessment; MC 4 (Best supportive care): i.e. end of treatment. In between MCs, follow-up calls are carried out to sustain communication. This study aimed to assess to what extent the MCA was implemented as planned and consolidated in specialized oncology practice. METHODS: A prospective observational process evaluation study was conducted, which focused on the implementation fidelity of the MCA. All MCs during two assessment periods were included. We analysed all written records of the conversations, which are part of the routine documentation during MCs and follow-up calls. Adherence to key aspects of the manual was documented on structured checklists at the beginning of the implementation of the MCA and after 6 months. The analysis was descriptive. Differences between the two assessment periods are analysed with chi-square tests. RESULTS: A total of 133 MCs and 54 follow-up-calls (t1) and of 172 MCs and 92 follow-up calls (t2) were analysed. MC 2 were the most frequently completed conversations (n = 51 and n = 47). Advance care planning was discussed in 26 and 13% of MC 2 in the respective assessment periods; in 31 and 47% of MC 2, prognostic awareness was recorded. The most frequently documented topic in the follow-up calls was the physical condition in patients (82 and 83%). CONCLUSION: The implementation of a trajectory-specific communication concept was largely successful. Additional studies are needed to understand how fidelity could be further improved. TRIAL REGISTRATION: DRKS00013469 / Date of registration: 22.12.2017.

[HeiMeKOM (Heidelberg Milestones Communication): development of an interprofessional intervention for improvement of communication in patients with limited prognosis]. / HeiMeKOM (Heidelberger Meilenstein Kommunikation): Entwicklung einer interprofessionellen Intervention zur Verbesserung der Kommunikation bei Patient*innen mit eingeschränkter Prognose.

BACKGROUND: The care for patients with advanced disease and limited prognosis and their relatives is complex and characterized by insufficient communication and lack of coordination and continuity. AIM: Development of an interprofessional, practice-guided concept of longitudinally structured communication with the goal of fostering communication, improving quality of life and facilitating early integration of palliative care. METHODS: Multi-level process starting from a draft with discussion and approval within the multiprofessional team and correlation with interviews with patients and relatives. Preparation of a comprehensive concept with review of the literature, problem analysis, theoretical foundation, goal setting and intervention components. Discussion of suitability for daily use, adaptation and further development of the concept. RESULTS AND CONCLUSIONS: Concept with the following components: interprofessional communication training, structured conversations at defined moments in a tandem of physician and nurse with patient and relative, follow-up conversations conducted by the nurse, and respective instruments (conversation protocol, question prompt list, memory cards). Only iterative discussion with and the approval of patients, relatives and the multiprofessional team and their approval will put the concept into practice.

Communication along Milestones in Lung Cancer Patients with Advanced Disease.

Patients with advanced lung cancer and their caregivers are confronted with a complex situation as their disease-related burden comprises physical, psychosocial, and spiritual needs. During the illness trajectory with limited prognosis, they are exposed to different multidisciplinary healthcare settings and providers that challenge the continuity and coordination of care. Additionally, decision-making between active cancer treatment and end-of-life care constitutes a continuous balancing act. Several studies have shown that early integration of palliative care and adequate advance care planning improve quality of life and satisfaction with care. For this strategy, the communication skills of healthcare providers and interprofessional collaboration should be strengthened. A longitudinally structured communication approach along pivotal milestones of the disease can empower patients by facilitating coping and prognostic awareness, and achieve early integration of palliative care and advance care planning. Good interprofessional collaboration and communication lead to better coordination and continuity of care.

The Heidelberg Milestones Communication Approach (MCA) for patients with prognosis <12 months: protocol for a mixed-methods study including a randomized controlled trial.

BACKGROUND: The care needs of patients with a limited prognosis (<12 months median) are complex and dynamic. Patients and caregivers must cope with many challenges, including physical symptoms and disabilities, uncertainty. and compromised self-efficacy. Healthcare is often characterized by disruptions in the transition between healthcare providers. The Milestones Communication Approach (MCA) is a structured, proactive, interprofessional concept that involves physicians and nurses and is aimed at providing coherent care across the disease trajectory. This study aims to evaluate these aspects of MCA: (1) the training of healthcare professionals, (2) implementation context and outcomes, (3) patient outcomes, and (4) effects on interprofessional collaboration. METHODS/DESIGN: A multiphase mixed-methods design will be used for the study. A total of 100 patients and 120 healthcare professionals in a specialized oncology hospital will be involved. The training outcomes will be documented using a questionnaire. Implementation context and outcomes will be explored through semi-structured interviews and written questionnaires with healthcare professionals and with the training participants and through a content analysis of patient files. Patient outcomes will be assessed in a pragmatic non-blinded randomized controlled trial and in qualitative interviews with patients and caregivers. Trial outcomes are supportive care needs (SCNS-SF34-G), quality of life (SeiQol and Fact-L), depression and anxiety symptoms (PHQ-4), and distress (Distress Thermometer). Qualitative semi-structured interviews on patients' views will focus on shared decision-making, communication needs, feeling empathy, and further utilization of healthcare services. Interprofessional collaboration will be explored using the UWE-IP-D before the implementation of MCA (t0) and after 3 (t1), 9 (t2), and 12 (t3) months. DISCUSSION: Using guideline-concordant early palliative care, MCA aims to foster patient-centered communication with shared decision-making and facilitation of advance care planning including end-of-life decisions, thus increasing patient quality of life and decreasing aggressive medical care at the end of life. It is assumed that the communication skills training and interprofessional coaching will improve the communication behavior of healthcare providers and influence team communications and team processes. TRIAL REGISTRATION: German Clinical Trials Register, DRKS00013649 and DRKS00013469. Registered on 22 December 2017.