Can a community of practice enhance a palliative approach for people drawing close to death with dementia?

This action research study was conducted to trial a strategy intended to support a consistent, high-quality, palliative approach for people with dementia drawing close to death-the implementation of a community of practice. Professionals from community/residential care and hospitals formed this community of practice, which took on the role of an action research group. The group was supported to identify and address practice problems. Four action plans were implemented; outcomes from two are reported. When actioning the plan 'providing education and information for the staff', the staff's ratings of sessions and resources were positive but impacts upon knowledge, views, or confidence were small. When actioning 'supporting families', families providing care in non-hospital settings received information about severe dementia from suitably prepared staff, plus contact details to access support. Family feedback was primarily positive. Reference to additional practice change frameworks and inclusion of specialist palliative care professionals are recommendations for future initiatives; also focusing on targeted, achievable goals over longer timeframes.

National consultation informing development of guidelines for a palliative approach for aged care in the community setting.

AIM: This study aimed to obtain perspectives from key stakeholders to inform the development of Australian national guidelines for a palliative approach to aged care in the community setting. METHODS: A descriptive, exploratory qualitative design was used. Sampling was purposive. Data were collected during audiotaped, semistructured, individual and focus group interviews that addressed the need for the guidelines and aimed to identify practice areas for inclusion. Thematic analysis was undertaken. RESULTS: Interviews were conducted across Australia and included 172 participants: health-care providers, consumers, volunteers and researchers/educators. Themes emerging from the data were: Provision of a Palliative Approach in Community Aged Care, Carer Support, Advance Care Planning, Physical and Psychological Symptom Assessment and Management, Psychosocial Support, Spiritual Support, Issues for Aboriginal or Torres Strait Islander People, Older People from Diverse Cultural and Language Groups, and Clients with Special Needs. CONCLUSION: Findings underpinned development of new guideline documents.

Online mental health resources in rural Australia: clinician perceptions of acceptability.

BACKGROUND: Online mental health resources have been proposed as an innovative means of overcoming barriers to accessing rural mental health services. However, clinicians tend to express lower satisfaction with online mental health resources than do clients. OBJECTIVE: To understand rural clinicians' attitudes towards the acceptability of online mental health resources as a treatment option in the rural context. METHODS: In-depth interviews were conducted with 21 rural clinicians (general practitioners, psychologists, psychiatrists, and clinical social workers). Interviews were supplemented with rural-specific vignettes, which described clinical scenarios in which referral to online mental health resources might be considered. Symbolic interactionism was used as the theoretical framework for the study, and interview transcripts were thematically analyzed using a constant comparative method. RESULTS: Clinicians were optimistic about the use of online mental health resources into the future, showing a preference for integration alongside existing services, and use as an adjunct rather than an alternative to traditional approaches. Key themes identified included perceptions of resources, clinician factors, client factors, and the rural and remote context. Clinicians favored resources that were user-friendly and could be integrated into their clinical practice. Barriers to use included a lack of time to explore resources, difficulty accessing training in the rural environment, and concerns about the lack of feedback from clients. Social pressure exerted within professional clinical networks contributed to a cautious approach to referring clients to online resources. CONCLUSIONS: Successful implementation of online mental health resources in the rural context requires attention to clinician perceptions of acceptability. Promotion of online mental health resources to rural clinicians should include information about resource effectiveness, enable integration with existing services, and provide opportunities for renegotiating the socially defined role of the clinician in the eHealth era.

Champions in a lifestyle risk-modification program: reflections on their training and experiences.

ISSUES ADDRESSED: The 'Waist' Disposal Challenge (WDC) is a lay-led community-based health intervention in Rotary clubs in Western Australia aimed at reducing risk factors leading to lifestyle-related chronic diseases and, in particular, obesity. Ninety-three lay health advisors (LHA) or Champions were trained to deliver educational sessions to their clubs (for 1300 peers) and implement a body mass index competition by taking monthly weigh-ins (for 764 peers). METHODS: A mixed method design was used to explore Champions' experiences with the training program and their perceived role and impact on implementing the program in their clubs in 2010-11. RESULTS: The qualitative data provided important evidence that initial implementation of this LHA-led health promotion intervention (WDC) has been effective and impacted positively on the Champions and their Rotary clubs. The results were a good fit in the two social action arenas of the Natural Helper Intervention Model: peer-to-peer social support and community attachment. CONCLUSIONS: Reflecting on the impact of the program in their clubs, Champions reported overall health improvements at the personal, peer and community levels, enhanced awareness about health-related issues, improved health behaviour and enhanced community capacity. So what? Champions are an important resource for providing self-management education to people who are at risk of developing chronic conditions, particularly for those hard to reach and where there are difficulties recruiting trained health professionals. Future research needs to explore the characteristics of Champions that impact on the success of community-based programs.

Developing and testing a strategy to enhance a palliative approach and care continuity for people who have dementia: study overview and protocol.

BACKGROUND: Typically, dementia involves progressive cognitive and functional deterioration, leading to death. A palliative approach recognizes the inevitable health decline, focusing on quality of life. The approach is holistic, proactive, supports the client and the family, and can be provided by the client's usual care team.In the last months of life, distressing symptoms, support needs, and care transitions may escalate. This project trialed a strategy intended to support a consistent, high quality, palliative approach for people with dementia drawing close to death. The strategy was to implement two communities of practice, drawn primarily from service provider organizations across care sectors, supporting them to address practice change. Communities comprised practitioners and other health professionals with a passionate commitment to dementia palliative care and the capacity to drive practice enhancement within partnering organizations.Project aims were to document: (i) changes driven by the communities of practice; (ii) changes in staff/practitioner characteristics during the study (knowledge of a palliative approach and dementia; confidence delivering palliative care; views on death and dying, palliative care, and a palliative approach for dementia); (iii) outcomes from perspectives of family carers, care providers, and community of practice members; (iv) the extent to which changes enhanced practice and care continuity; and (v) barriers to and facilitators of successful community of practice implementation. METHODS/DESIGN: This action research project was implemented over 14 months in 2010/11 in metropolitan Perth, Western Australia and regional Launceston, Tasmania. Each state based community of practice worked with the researchers to scope existing practice and its outcomes. The research team compiled a report of existing practice recommendations and resources. Findings of these two steps informed community of practice action plans and development of additional resources. Change implementation was recorded and explored in interviews, comparisons being made with practice recommendations. Changes in staff/practitioner characteristics were evaluated using survey data. Findings from semi structured interviews and survey administration established outcomes from perspectives of family carers, care providers, and community of practice members. Consideration of processes and outcomes, across the two state based settings, informed identification of barriers and facilitators. Community of practice reflections also informed study recommendations.

Guidelines for a palliative approach for aged care in the community setting: A suite of resources.

In Australia, many people ageing in their own homes are becoming increasingly frail and unwell, approaching the end of life. A palliative approach, which adheres to palliative care principles, is often appropriate. These principles provide a framework for proactive and holistic care in which quality of life and of dying is prioritised, as is support for families. A palliative approach can be delivered by the general practitioner working with the community aged care team, in collaboration with family carers. Support from specialist palliative care services is available if necessary.The Guidelines for a Palliative Approach for Aged Care in the Community Setting were published by the Australian Government Department of Health and Ageing to inform practice in this area. There are three resource documents. The main document provides practical evidence based guidelines, good practice points, tools, and links to resources. This document is written for general practitioners, nurses, social workers, therapists, pastoral care workers, and other health professionals and responded to needs identified during national consultation. Evidence based guidelines were underpinned by systematic reviews of the research literature. Good practice points were developed from literature reviews and expert opinion. Two 'plain English' booklets were developed in a process involving consumer consultation; one is for older people and their families, the other for care workers.The resources are intended to facilitate home care that acknowledges and plans for the client's deteriorating functional trajectory and inevitable death. At a time when hospitals and residential aged care facilities are under enormous pressure as the population ages, such a planned approach makes sense for the health system as a whole. The approach also makes sense for older people who wish to die in their own homes. Family needs are recognised and addressed. Unnecessary hospitalisations or residential placements and clinically futile interventions are also minimised.

Developing a sustainable model of rural cancer care: the Western Australian Cancer Network project.

PROBLEM: Cancer-related mortality is higher in rural areas than in urban centres. One of the contributing factors is limited access to treatment options in rural areas. DESIGN: An evaluation of the effectiveness of the Western Australian Cancer Network (CanNET WA) pilot project was undertaken using qualitative methods and document analysis. SETTING: CanNET WA was established in the Great Southern region of Western Australia. KEY MEASURES FOR IMPROVEMENT: Three measures were assessed: impact of the CanNET WA on consumers, care providers and changes to systems and processes. STRATEGIES FOR CHANGE: CanNET WA comprised a number of initiatives that together led to an improvement in cancer care. These included a multidisciplinary cancer team, improved access to visiting medical specialists, formal links with tertiary cancer centres, increased primary health involvement in cancer care and increased education regarding cancer care for local health care providers. EFFECTS OF CHANGE: Changes in the three key outcome measures were reported. Consumers had greater choice of treatment options and had more involvement in decision making. Health professionals reported improvements in care coordination and in peer support related to the new multidisciplinary cancer care team, and improved links with tertiary cancer centres in Perth. Systemic changes included mapping of referral pathways and tumour-specific care pathways. LESSONS LEARNT: CanNET WA has demonstrated the need for coordinated cancer care for rural people that offers care locally whenever possible. The success of the project paved the way for the rollout of the CanNET WA concept into other regional areas of Western Australia.

The diagnosis and treatment decisions of cancer patients in rural Western Australia.

BACKGROUND: People living in rural areas who have a diagnosis of cancer have poorer outcomes than people living in urban centers. The reasons for this are unclear. Little is known about the impact that living in a rural area has on the diagnosis and treatment decisions of these people and how these may in turn impact on care outcomes. OBJECTIVES: This study explored the reasons why people living in rural areas may delay diagnosis and what issues affected the decisions they made regarding their cancer treatment. METHODS: In depth, semistructured interviews were conducted with 18 participants from 3 rural Western Australian health regions. Content analysis was used to develop themes. RESULTS: Four themes were identified to describe the rural cancer experience. The first 3 themes, Experiences of Diagnosis and Referral, The Treatment Journey, and Managing your own Care, relate to the experiences of rural cancer patients during their journey through the health care system. The final overarching theme, Implicit Faith, described the level of confidence that rural cancer patients had in the health system, often despite delays and inconveniences. CONCLUSIONS: There is a need to improve primary health care and care coordination for rural cancer patients living in Australia and to promote self-advocacy and consumer empowerment for rural cancer patients. IMPLICATIONS FOR PRACTICE: Rural patients need help and support throughout their cancer journey, including through the process of diagnosis.

Descriptive, exploratory study of the role of nursing assistants in Australian residential aged care facilities: the example of pain management.

AIM: This study explored the experiences of nursing assistants (NAs) who work with older people in residential aged care facilities (RACFs), to ascertain their role in Australian RACFs. Experiences with pain management were used as an example to explore their work role. METHODS: A descriptive, exploratory qualitative approach was used to examine NAs' experiences. Participants included six NAs from three RACFs in regional Western Australia. In-depth interviews focused on the NAs' experiences of providing care to older people in RACFs and in particular their experiences providing pain management for residents. RESULTS: The role of NAs often extends beyond their scope of practice. NAs describe making clinical decisions, initiating clinical care and advocating for residents. CONCLUSIONS: NAs represent a majority of the staff in Australian RACFs and they have a significant role in clinical care. There is a need to ensure that NAs are adequately prepared and supported in their role.

Understanding nursing assistants' experiences of caring for older people in pain: the Australian experience.

This study examined the experiences of nursing assistants (NAs), who have worked with older people in residential aged care facilities (RACFs) who are in pain, to ascertain the role that NAs play in the pain management process. A descriptive, exploratory qualitative approach was used to examine NAs' experiences. Six NAs employed in three RACFs in regional Western Australia participated in the study. In-depth interviews focusing on the NAs' experiences of caring for older people in pain were conducted. This study provided an understanding of the care needs of older residents in pain and illuminated the role of NAs in the pain management process. The central role that NAs play in RACFs was highlighted, as were the responsibilities associated with pain management. Nursing assistants may be responsible for initiating and implementing pain management treatments for older residents. This is outside the scope of practice for NAs; therefore, it is imperative that the preparation of NAs give them adequate knowledge to perform this role. As well, it may be timely to consider regulation of this large group of workers who are performing clinical tasks in RACFs.

Spreading and fingering in spin coating.

We study the spreading and fingering of drops of silicone oil on a rotating substrate for a range of rotation speeds and drop volumes. The spreading of the drop prior to the onset of fingering is found to follow the theoretically predicted time dependence, but with a large shift in time scale. For the full range of experimental parameters studied, the contact line becomes unstable and fingers develop when the radius of the drop becomes sufficiently large. We study the growth of perturbations around the perimeter of the drop and find the growth rate of the most unstable mode to agree well with the predictions of lubrication theory. The number of fingers which form around the perimeter of the drop is found to be a function of both rotation speed and drop volume, and is also in excellent agreement with theoretical predictions.

Morphology and scaling of impact craters in granular media.

We present the results of experiments on impact craters formed by dropping a steel ball vertically into a container of small glass beads. As the energy of impact increases, we observe a progression of crater morphologies analogous to that seen in craters on the moon. We find that both the diameter and the depth of the craters are proportional to the 1/4 power of the energy. The ratio of crater diameter to rim-to-floor depth is constant for low-energy impacts, but increases at higher energy, similar to what is observed for lunar craters.