Position paper on undergraduate Palliative Medicine education for doctors in South Africa.

BACKGROUND:  Basic palliative care teaching should be included in training curricula for health care providers (HCPs) at all levels of the health service to ensure that the goal set by the South African (SA) National Policy Framework and Strategy for Palliative Care, to have an adequate number of appropriately trained HCPs in South Africa, is achieved. Furthermore, palliative learning objectives for nurses and doctors should be standardised. Many SA medical schools have integrated elements of Palliative Medicine (PM) teaching into undergraduate medical training programmes for doctors; however, the degree of integration varies widely, and consensus and standardisation of the content, structure and delivery of such PM training programmes are not yet a reality. AIM:  This joint position paper aims to describe the current state of undergraduate medical PM teaching in South Africa and define the PM competencies required for an SA generalist doctor. SETTING:  Palliative Medicine programme leads and teachers from eight medical schools in South Africa. METHODS:  A survey exploring the structure, organisation and content of the respective medical undergraduate PM programmes was distributed to PM programme leads and teachers. RESULTS:  Responses were received from seven medical schools. Through a process of iterative review, competencies were defined and further grouped according to suitability for the pre-clinical and clinical components of the curriculum. CONCLUSION:  Through mapping out these competencies in a spiralled medical curriculum, the authors hope to provide guidance to medical curriculum designers to effectively integrate PM teaching and learning into current curricula in line with the goals of the SA National Policy Framework and Strategy on Palliative Care (NPFSPC).

A Delphi study to guide the development of a clinical indicator tool for palliative care in South Africa.

BACKGROUND:  The South African National Policy Framework and Strategy on Palliative Care (NPFSPC) recommends that when integrating palliative care (PC) into the health system, a PC indicators tool should be used to guide clinicians to recognise a patient who should receive PC. The policy document recommends 'a simple screening tool developed for use in South Africa that would assist healthcare professionals (HCPs) to recognise patients who may have unmet palliative care needs'. AIM:  This research study sought to develop South African consensus on indicators for PC to assist clinicians to recognise a patient in need of PC. SETTING:  The South African healthcare setting. METHODS:  A Delphi study was considered suitable as a methodology to develop consensus. The methodology was based on the Conducting and REporting of DElphi studies (CREDES) guidance on Delphi studies to ensure rigour and transparency in conducting and reporting. Six different Delphi rounds were used to develop consensus. Each round allowed participants to anonymously rate statements with predefined rating scales. RESULTS:  Cognisant of the disparities in healthcare provision and access to equitable healthcare in South Africa, the expert advisory group recommended, especially for South Africa, that 'this tool is for deteriorating patients with an advanced life-limiting illness where all available and appropriate management for underlying illnesses and reversible complications has been offered'. The expert advisory group felt that disease-specific indicators should be described before the general indicators in the South African indicators tool, so all users of the tool orientate themselves to the disease categories first. This study included three new domains to address the South African context: trauma, infectious diseases and haematological diseases. General indicators for PC aligned with the original Supportive and Palliative Care Indicators Tool (SPICT) tool. CONCLUSION:  The Supportive and Palliative Care Indicators Tool for South Africa (SPICTTM-SA) is a simple screening tool for South Africa that may assist HCPs to recognise patients who may have unmet PC needs.

Shaping the Future of Probiotics and Prebiotics.

Recent and ongoing developments in microbiome science are enabling new frontiers of research for probiotics and prebiotics. Novel types, mechanisms, and applications currently under study have the potential to change scientific understanding as well as nutritional and healthcare applications of these interventions. The expansion of related fields of microbiome-targeted interventions, and an evolving landscape for implementation across regulatory, policy, prescriber, and consumer spheres, portends an era of significant change. In this review we examine recent, emerging, and anticipated trends in probiotic and prebiotic science, and create a vision for broad areas of developing influence in the field.

Primary palliative care competency framework for primary care and family physicians in India-Collaborative work by Indian Association of Palliative Care and Academy of Family Physicians of India.

The discrepancy in the demand for palliative care and distribution of specialist palliative care services will force patients to be eventually cared for by primary care/family physicians in the community. This will necessitate primary care/family physicians to equip themselves with knowledge and skills of primary palliative care. Indian National Health Policy (2017) recommended the creation of continuing education programs as a method to empower primary care/family physicians. With this intention, a taskforce was convened for incorporating primary palliative care into family/primary care practice. The taskforce comprising of National and International faculties from Palliative Care and Family Medicine published a position paper in 2018 and subsequently brainstormed on the competency framework required for empowering primary care/family physicians. The competencies were covered under the following domains: knowledge, skills and attitude, ethical and legal aspects, communication and team work. The competency framework will be presented to the National Board of Examinations recommending to be incorporated in the DNB curriculum for Family Medicine.

Joint position statement Indian Association of Palliative Care and Academy of Family Physicians of India - The way forward for developing community-based palliative care program throughout India: Policy, education, and service delivery considerations.

PURPOSE: This joint position statement, by the Indian Association of Palliative Care (IAPC) and Academy of Family Physicians of India (AFPI), proposes to address gaps in palliative care provision in the country by developing a community-based palliative care model that will empower primary care physicians to provide basic palliative care. EVIDENCE: India ranks very poorly, 67th of 80 countries in the quality of death index. Two-thirds of patients who die need palliative care and many such patients spend the last hours of life in the Intensive care unit. The Indian National Health Policy (NHP) 2017 and other international bodies endorse palliative care as an essential health-care service component. NHP 2017 also recommends development of distance and continuing education options for general practitioners to upgrade their skills to provide timely interventions and avoid unnecessary referrals. METHODS: A taskforce was formed with Indian and International expertise in palliative care and family medicine to develop this paper including an open conference at the IAPC conference 2017, agreement of a formal liaison between IAPC and AFPI and wide consultation leading to the development of this position paper aimed at supporting integration, networking, and joint working between palliative care specialists and generalists. The WHO model of taking a public health approach to palliative care was used as a framework for potential developments; policy support, education and training, service development, and availability of appropriate medicines. RECOMMENDATIONS: This taskforce recommends the following (1) Palliative care should be integrated into all levels of care including primary care with clear referral pathways, networking between palliative care specialist centers and family medicine physicians and generalists in community settings, to support education and clinical services. (2) Implement the recommendations of NHP 2017 to develop services and training programs for upskilling of primary care doctors in public and private sector. (3) Include palliative care as a mandatory component in the undergraduate (MBBS) and postgraduate curriculum of family physicians. (4) Improve access to necessary medications in urban and rural areas. (5) Provide relevant in-service training and support for palliative care to all levels of service providers including primary care and community staff. (6) Generate public awareness about palliative care and empower the community to identify those with chronic disease and provide support for those choosing to die at home.

Futurism in nursing: Technology, robotics and the fundamentals of care.

AIMS AND OBJECTIVES: To explore the concept of futurism and the emergence of robotics in relation to the fundamentals of care, highlighting how nurses need a more anticipatory and contemporary position towards technology to maintain relevance in the future. BACKGROUND: The future of nursing in Western countries will soon be linked with the emergence of robotics for efficient and cost-effective provision of fundamental care. Their emergence and roles with care of the body and more broadly assisting people with their daily living activities has enormous implications for the profession and health care. Despite this importance, how nursing understands and will respond to technological trends and developments is insufficiently reflected in the professions discourse. DESIGN: A discursive article. METHODS: Literature from nursing fundamentals of care/fundamental care, information science, technology, humanities and philosophy informed the arguments in this article. CONCLUSIONS: This article examines the intersection of futurism and the fundamentals of care, and how adopting an anticipatory and posthuman perspective towards technological-care integration is necessary amidst a robot revolution in the techno-era. RELEVANCE TO CLINICAL PRACTICE: Nurses are currently challenged to understand, prioritise and deliver fundamental care. Health systems are challenged by a lack of care predicated by shortfalls in skilled staff and deficiencies in staff mobilisation. Both challenges can be compounded or alleviated by further integration of technology, but to maximise benefit requires forethought and understanding. This article can help open needed dialogue around planning for the future and is a call to action for the nursing profession to conceptualise its position on exponential technological growth and fundamental care provision.

Elders' Experiences During Return Visits to the Emergency Department: A Phenomenographic Study in Taiwan.

BACKGROUND: Elders often experience multiple chronic diseases associated with frequent early return visits to emergency departments (EDs). There is limited knowledge of the experiences and concerns of elders during ED return visits. OBJECTIVES: The purpose of the research was to explore the experiences of elders during ED return visits, with a view toward identifying factors that contribute to return visits. METHODS: The qualitative approach of phenomenography was used. Data were collected at one ED in a 3,000-bed medical center in Taiwan. Inclusion criteria were aged 65 or above and return visits to the ED within 72 hours of discharge from an index ED visit. The seven steps of qualitative data analysis for a phenomenographic study were employed to develop understanding of participants' experiences. RESULTS: Thirty return-visit elders were interviewed in 2014. Four categories of description were established from the participants' accounts. These were "being tricked by ED staff," "doctor shopping," "a sign of impending death," and "feeling fatalistic." The outcome space of elders with early return visits to ED was characterized as "seeking the answer." CONCLUSION: Index ED visits are linked to return visits for Taiwanese elders through physiological, psychological, and social factors.

Workplace violence against emergency nurses in Taiwan: A phenomenographic study.

BACKGROUND: Workplace violence (WPV) is a serious problem in health care in Taiwan, as it is worldwide. Among all nursing staff, emergency department (ED) nurses are at the highest risk of WPV; yet, little attention has been paid to nurses as WPV victims. PURPOSE: The purpose of the study was to understand ED nurses' WPV experiences and perspectives. METHODS: An interpretive qualitative phenomenographic design was used to answer the following research question: what are the qualitatively different ways in which nurses in Taiwan experience WPV in the ED? Thirty ED nurses who identified as experienced with WPV were interviewed, and phenomenographic analysis was used to assess the data. FINDINGS: Four categories of description emerged. WPV was seen as a continuing nightmare, a part of daily life, and a direct threat, and it had a negative impact on nurses' passion for emergency care. WPV adversely affected nurses on physical, psychological, social, personal, and professional levels. CONCLUSION: The findings of this study have practical implications for in-service WPV training programs and may be used to inform potential changes to policy and legislation designed to establish a safer ED environment for staff.

Waiting and hoping: a phenomenographic study of the experiences of boarded patients in the emergency department.

AIMS AND OBJECTIVES: To understand the experiences and concerns of patients in the emergency department during inpatient boarding. BACKGROUND: Boarding in the emergency department is an increasingly common phenomenon worldwide. Emergency department staff, patients and their families become more stressed as the duration of boarding in the emergency department increases. Yet, there is limited knowledge of the experiences and concerns of boarded patients. DESIGN: The qualitative approach of phenomenography was used in the study. METHODS: The phenomenographic study was conducted in one emergency department that treats approximately 15,000 patients each month. Twenty emergency department boarding patients were recruited between July-September 2014. Semi-structured interviews were used for data collection. The seven steps of qualitative data analysis for a phenomenographic study - familiarisation, articulation, condensation, grouping, comparison, labelling and contrasting - were employed to develop an understanding of participants' experiences and concerns during their inpatient boarding in the emergency department. RESULTS: The perceptions that emerged from the data were collected into four categories of description of the phenomenon of emergency department boarding patients: a helpless choice; loyalty to specific hospitals and doctors; an inevitable challenge of life; and distrust of the healthcare system. The outcome space for the emergency department boarding patients was waiting and hoping for a cure. CONCLUSION: The experiences and concerns of emergency department boarding patients include physical, psychological, spiritual and health system dimensions. It is necessary to develop an integrated model of care for these patients. RELEVANCE TO CLINICAL PRACTICE: Understanding the experiences and concerns of patients who are placed on boarding status in the ED will help emergency healthcare professionals to improve the quality of emergency care. There is a need to develop a care model and associated intervention measures for emergency department patients during the boarding process. The results of this study will help health regulatory authorities to develop an appropriate emergency department boarding system so that patients receive better emergency care.

The emergency patient's participation in medical decision-making.

AIMS AND OBJECTIVES: The purpose of this research was to explore the medical decision-making processes of patients in emergency departments. BACKGROUND: Studies indicate that patients should be given enough time to acquire relevant information and receive adequate support when they need to make medical decisions. It is difficult to satisfy these requirements in emergency situations. Limited research has addressed the topic of decision-making among emergency patients. DESIGN: This qualitative study used a broadly defined grounded theory approach to explore decision-making in an emergency department in Taiwan. METHODS: Thirty emergency patients were recruited between June and December 2011 for semi-structured interviews that were audio-taped and transcribed verbatim. RESULTS: The study identified three stages in medical decision-making by emergency patients: predecision (interpreting the problem); decision (a balancing act) and postdecision (reclaiming the self). Transference was identified as the core category and pattern of behaviour through which patients resolved their main concerns. This transference around decision-making represents a type of bricolage. CONCLUSIONS: The findings fill a gap in knowledge about the decision-making process among emergency patients. RELEVANCE TO CLINICAL PRACTICE: The results inform emergency professionals seeking to support patients faced with complex medical decision-making and suggest an emphasis on informed patient decision-making, advocacy, patient-centred care and in-service education of health staff.

Director ofnursingexperiencesofa hospital inthenursinghomeprogramin South EastQueensland.

In Australiathereislimitedaccesstoacutecaresupportforresidentslivingwithin the residentialagedcaresector.Competingdemandsfromfamilies,residents,government agencies andtheacutecaresectorhasmeantthatstaffwiththesectorstruggleoftento meet theacutecareneedsofresidents,leadingsometimestotransferofresidentsto emergency departmentswithmajorhospitals.Hospitalinthenursinghomeisacaredeliverymodel designed to reduce transfers, facilitate appropriate care intervention, effectively utilize existing healthresources,andextendsupporttotheresidentialcaresector.Thisresearchproject used aninterpretivequalitativeframeworktoexplorethroughfocusgroupmethod,hospital in thehomeexperiencesof20residentialcareDirectorsofNursinginSouthEastQueensland. Researchoutcomesemphasizehospitalinthenursinghomeasamutuallybeneficialsupport strategy thatcanimproveresidentialbasedmanagementofacuteandchronicillness,can positively assistfamilysupport,andassistswithdecisionmakingandongoingcommunication. Hospital inthehomeemphasisesamovefromhospitaldestinationbasedacutecareservicesto community based delivery supported by a multidisciplinary team.

SUPPORTING CLINICAL FACILITATORS THROUGH PEER REVIEW OF TEACHING.

The QUT School of Nursing is currently trialling peer review of teaching (PRoT) as one strategy to support clinical facilitators working with undergraduate students. Work integrated learning (WIL) relies on collaborative partnerships and clinical facilitators need specific skills and knowledge.

Registered Nurses and Discharge Planning in a Taiwanese ED: A Neglected Issue?

Published research on discharge planning is written from the perspective of hospital wards and community services. Limited research focuses on discharge planning in the emergency department (ED). The objective of this study was to identify ED nurses' perceptions of factors influencing the implementation of discharge planning. This qualitative study collected data from 25 ED nurses through in-depth interviews and a drawing task in which participants were asked to depict on paper the implementation of discharge planning in their practice. Factors influencing discharge planning were grouped into three categories: discharge planning as a neglected issue in the ED, heavy workload, and the negative attitudes of ED patients and their families. The study highlighted a need for effective discharge planning to be counted as an essential clinical competency for ED nurses and factored into their everyday workload. Nurses perceived that organizational culture, and parents' and relatives' attitudes were barriers to implementing discharge teaching in the ED.

Radical nursing and the emergence of technique as healthcare technology.

The integration of technology in care is core business in nursing and this role requires that we must understand and use technology informed by evidence that goes much deeper and broader than actions and behaviours. We need to delve more deeply into its complexity because there is nothing minor or insignificant about technology as a major influence in healthcare outcomes and experiences. Evidence is needed that addresses technology and nursing from perspectives that examine the effects of technology, especially related to increasing demands for efficiency, the relationship of technology to nursing and caring, and a range of philosophical questions associated with empowering people in their healthcare choices. Specifically, there is a need to confront in practice the ways technique influences care. Technique is the creation of a kind of thinking that is necessary for contemporary healthcare technology to develop and be applied in an efficient and rational manner. Technique is not an entity or specific thing, but rather a way of thinking that seeks to shape and organize nursing activity, and manage efficiently individual difference(s) in care. It emphasizes predetermined causal relationships, conformity, and sameness of product, process, and thought. In response is needed a radical vision of nursing that attempts in a real sense to ensure we meet the needs of individuals and their community. Activism and advocacy are needed, and a willingness to create a certain detachment from the imperatives that technique demands. It is argued that our responsibility as nurses is to respond in practice to the errors, advantages, difficulties, and temptations of technology for the benefit of those who most need our assistance and care.

Promoting palliative care in the community: production of the primary palliative care toolkit by the European Association of Palliative Care Taskforce in primary palliative care.

BACKGROUND: A multidisciplinary European Association of Palliative Care Taskforce was established to scope the extent of and learn what facilitates and hinders the development of palliative care in the community across Europe. AIM: To document the barriers and facilitators for palliative care in the community and to produce a resource toolkit that palliative care specialists, primary care health professionals or policymakers, service developers, educationalists and national groups more generally could use to facilitate the development of palliative care in their own country. DESIGN: (1) A survey instrument was sent to general practitioners with knowledge of palliative care services in the community in a diverse sample of European countries. We also conducted an international systematic review of tools used to identify people for palliative care in the community. (2) A draft toolkit was then constructed suggesting how individual countries might best address these issues, and an online survey was then set up for general practitioners and specialists to make comments. Iterations of the toolkit were then presented at international palliative care and primary care conferences. RESULTS: Being unable to identify appropriate patients for palliative care in the community was a major barrier internationally. The systematic review identified tools that might be used to help address this. Various facilitators such as national strategies were identified. A primary palliative care toolkit has been produced and refined, together with associated guidance. CONCLUSION: Many barriers and facilitators were identified. The primary palliative care toolkit can help community-based palliative care services to be established nationally.

Women's perceptions of their healthcare experience when they choose not to breastfeed.

RESEARCH QUESTION: How do women who choose not to breastfeed perceive their healthcare experience? METHOD: This qualitative research study used a phenomenographic approach to explore the healthcare experience of women who do not breastfeed. Seven women were interviewed about their healthcare experience relating to their choice of feeding, approximately 4 weeks after giving birth. Six conceptions were identified and an outcome space was developed to demonstrate the relationships and meaning of the conceptions in a visual format. FINDINGS: There were five unmet needs identified by the participants during this study. These needs included equity, self sufficiency, support, education and the need not to feel pressured. CONCLUSION: Women in this study who chose not to breastfeed identified important areas where they felt that their needs were not met. In keeping with the Code of Ethics for Nurses and Midwives, the identified needs of women who do not breastfeed must be addressed in a caring, compassionate and just manner. The care and education of women who formula feed should be of the highest standard possible, even if the choice not to breastfeed is not the preferred choice of healthcare professionals.

Teaching undergraduate students community nursing: using action research to increase engagement and learning.

Nurses play a pivotal role in responding to the changing needs of community health care. Therefore, nursing education must be relevant, responsive, and evidence based. We report a case study of curriculum development in a community nursing unit embedded within an undergraduate nursing degree. We used action research to develop, deliver, evaluate, and redesign the curriculum. Feedback was obtained through self-reflection, expert opinion from community stakeholders, formal student evaluation, and critical review. Changes made, especially in curriculum delivery, led to improved learner focus and more clearly linked theory and practice. The redesigned unit improved performance, measured with the university's student evaluation of feedback instrument (increased from 0.3 to 0.5 points below to 0.1 to 0.5 points above faculty mean in all domains), and was well received by teaching staff. The process confirmed that improved pedagogy can increase student engagement with content and perception of a unit as relevant to future practice.

Schizophrenia and the progression of emotional expression in relation to others.

Gaining an improved understanding of people diagnosed with schizophrenia has the potential to influence priorities for therapy. Psychosis is commonly understood through the perspective of the medical model. However, the experience of social context surrounding psychosis is not well understood. In this research project we used a phenomenological methodology with a longitudinal design to interview 7 participants across a 12-month period to understand the social experiences surrounding psychosis. Eleven themes were explicated and divided into two phases of the illness experience: (a) transition into emotional shutdown included the experiences of not being acknowledged, relational confusion, not being expressive, detachment, reliving the past, and having no sense of direction; and (b) recovery from emotional shutdown included the experiences of being acknowledged, expression, resolution, independence, and a sense of direction. The experiential themes provide clinicians with new insights to better assess vulnerability, and have the potential to inform goals for therapy.