Interprofessional collaboration in telemedicine for long-term care: An exploratory qualitative study.

BACKGROUND: Widespread and sustained adoption of telemedicine in long-term residential care is emerging. Nursing home (NH) nurses play a key role in collaborating with remote physicians to manage residents' medical conditions through videoconferencing. Therefore, understanding of interprofessional collaboration and effective communication between nurses and physicians is critical to ensure quality of care and safety during teleconsultations. AIMS: To explore NH nurses' and physicians' experiences of interprofessional collaboration and communication during teleconsultations. METHODS: A qualitative descriptive design was adopted. Purposive sampling was conducted to recruit 22 physicians and nurses involved in NH teleconsultations. Semi-structured online interviews were conducted, and data were thematically analyzed. RESULTS: Three themes were identified: (1) Manner of communication in telemedicine, (2) sociocultural influences in collaborative practice, and (3) role expectations in telemedicine. Both nurses and physicians recognized the importance of building and maintaining trust as physicians heavily depended on nurses for provision of objective information for clinical decision-making. However, practice differences were observed between nurses and physicians during teleconsultations. Sociocultural influences such as power relations and language barriers also affected the nurse-physician relationship and interpersonal communication. Additionally, different performance expectations were identified between nurses and physicians. CONCLUSION: Interprofessional collaboration in teleconsultations is challenging because of lack of in-person assessment and dependence on nurses for clinical information. In addition, expectations and communication styles differ among healthcare professionals. This study called for interprofessional telemedicine training with incorporation of shared mental models to improve role clarity and communication. Given the international-dominated healthcare workforce in long-term care, the development of cultural competency could also be considered in telemedicine training to enhance nurse-physician collaborative practice. CLINICAL RELEVANCE: Telemedicine is increasingly adopted in long-term care settings, where multidisciplinary healthcare professionals from different health institutions are involved in resident care. Interprofessional collaboration should be incorporated into telehealth education for enhanced clinical practice in this care delivery model.

Attitudes towards the dying and death anxiety in acute care nurses - can a workshop make any difference? A mixed-methods evaluation.

OBJECTIVES: In Singapore, the core curriculum for end-of-life (EOL) care used in nurse training courses is limited. Only 45% of nurses indicated familiarity with inpatient palliative care. Nurses who lack skills in palliative care may develop anxiety and negative attitudes towards caring for dying patients. We explored whether a two-day, multimodal EOL care workshop could reduce nurses' death anxiety and improve nurses' skills, knowledge, and attitude towards palliative care. METHODS: Forty-five nurses participated in the workshop. At baseline before and at six weeks after, a 20-item knowledge-based questionnaire and the Death Attitude Profile-Revised (DAP-R) were administered. Six weeks post-workshop, in-depth interviews were conducted. We employed descriptive statistics, student paired samples t-test and inductive thematic analysis. RESULTS: There was a significant improvement in nurses' knowledge score (p < 0.01) and reduction in their death anxiety score (p < 0.01). Fear of Death (p = 0.025) and Death Avoidance (p = 0.047) sub-scores decreased significantly. However, the remaining domains such as Neutral Acceptance, Approach Acceptance, and Escape Acceptance did not show any significant difference, although Escape Acceptance showed a trend towards a reduced score (p = 0.063). After the workshop, more nurses adopted the Neutral Acceptance stance (76.2%), and none of them fell into the Fear of Death subdomain. Most nurses interviewed reported a positive change in their knowledge, attitudes, and practice even after the workshop. SIGNIFICANCE OF RESULTS: The multimodal palliative care workshop was useful in improving nurses' EOL knowledge and reducing their anxiety towards death. The positive change in nurses' attitudes and practices were noted to be sustained for at least six weeks after the intervention.

Facts to Snacks. Evaluating the Effectiveness of Bite-Sized Animations in Teaching Palliative Care to Medical Students.

BACKGROUND: Current palliative care training in medical school is inadequate in preparing doctors to provide quality palliative care. Little attention is paid to determining effective methods of training. OBJECTIVE: To assess the use of bite-sized animations in improving the confidence, knowledge and attitudes of medical students towards palliative care. METHODS: A mixed methods cohort study was adopted for the study. 50 medical students without prior palliative training completed questionnaires before and after watching a 12-part animated palliative care video series called PowerFacts. Of these participants, 18 underwent semi-structured interviews. RESULTS: The quantitative results showed that animations are effective in improving the confidence (P < .001) and knowledge (P < .001), but not the attitudes (P = .183) of medical students. Confidence, knowledge and attitudes were not correlated. Analysis of follow-up interviews of a convenience sample of participants showed that animations can be effective in teaching knowledge and does fill some gaps in palliative education for medical undergraduates. However, the content delivered as a sole learning tool is inadequate in preparing medical students for clinical practice. CONCLUSION: All participants achieved level 1 (reaction), some achieved level 2 (learning) but most did not achieve level 3 (behaviour) of the Kirkpatrick's model. There is a need for a multimodal approach in the comprehensive teaching of palliative care in undergraduate medical training to achieve all four levels of the Kirkpatrick Model.

Telemedicine entrustable professional activities for nurses in long-term care: A modified Delphi study.

BACKGROUND: As the use of telemedicine proliferates in community care, it is essential to ensure practice recommendations and guidelines are available to assist healthcare providers in providing telemedicine-based care. This study aimed to develop entrustable professional activities (EPAs) for nursing home nurses involved in telemedicine consultations. AIM: To develop entrustable professional activities (EPAs) for nursing home nurses involved in telemedicine consultations. DESIGN: Modified Delphi study. METHODS: The study was conducted in two stages. First, content analysis of 28 healthcare provider interviews and literature review on telemedicine competencies was conducted to develop an initial list of EPAs. An expert workgroup comprising of an international panel of academics and clinicians reviewed the activities. In the second stage, a three-round e-Delphi technique was used to develop telemedicine EPAs for nurses in long-term care. Descriptive statistics and qualitative feedback were distributed to participants after each round. Agreement within survey rounds was computed. RESULTS: Six core telemedicine EPAs with 28 descriptors were developed, from preparing the resident for the teleconsultation encounter to follow-up care post-teleconsultation. Agreement coefficients were high across all Delphi rounds. CONCLUSION: This study identifies the core functions that long-term care nurses' are expected to perform in telemedicine consultations. The internationally relevant EPAs are sufficiently broad to be adapted to design telemedicine training and workplace-based assessment for nurses. Organisations may utilise the EPAs as a resource during the implementation process of telemedicine services in long-term care in designing nursing workflow and complement the learning and development of nurses for telemedicine services. Equipping long-term care nurses with this resource can ensure consistency, patient safety and quality of teleconsultations delivered to nursing home residents. However, further work is required to expand the EPAs for application to practice.

Does an Integrated Palliative Care Program Reduce Emergency Department Transfers for Nursing Home Palliative Residents?

Background: Nursing homes (NHs) are faced with a myriad of challenges to provide quality palliative care to residents who are at their end of life. Objectives: To describe and examine the impact of the GeriCare Palliative Care Program, which comprises telemedicine, on-site clinical preceptorship, palliative care education program, and Advance Care Planning (ACP) advocacy in reducing emergency department (ED) transfers from NHs. Design: Retrospective cohort study. Setting/Subjects: A total of 217 telemedicine consults were conducted for 187 unique NH residents across 5 NHs in Singapore over a 27-month period from April 2018 to June 2020. Measurement: Records of all enrolled palliative care residents who were triaged by telemedicine consultations were examined. Results: Our findings revealed that 82% of our urgent telemedicine consultations have successfully averted ED transfers. Gender and completion of ACP were statistically significant between ED transfer group and non-ED transfer group. Among those who completed their ACP, 78.3% of the ED transfer group chose limited intervention as their main goals of care compared with 30% in the non-ED transfer group. Conclusions: The GeriCare Palliative Care Program is a novel program, which is developed to improve the quality of palliative care in NHs. The comprehensive GeriCare model comprises a systematic framework, an integration of clinical support, ACP advocacy, and education program. Our findings demonstrated that these interventions synergistically led to a reduction in ED transfers while optimizing the residents' quality of care. By carrying out the targeted initiatives to support NHs, the residents could age-in-place comfortably.

Understanding Quality of Life for Palliative Patients With Dysphagia Using the Swallowing Quality of Life (SWAL-QOL) Questionnaire.

OBJECTIVE: There are few studies concerning the differences in quality-of-life (QOL) between palliative care patients with and without dysphagia to date. We aimed to compare the QOL and symptoms in palliative patients with and without dysphagia using Swallowing Quality of Life (SWAL-QOL). METHODS: Eighty-one palliative patients with and without dysphagia underwent the SWAL-QOL questionnaire. A series of Mann Whitney U tests were performed between non-dysphagic and dysphagic groups for the total SWAL-QOL score and the 11 SWAL-QOL domains. RESULTS: Dysphagia significantly impacted patients' QOL in the dysphagic group (mean, 69.5; SD 21.9) than non-dysphagic group (mean, 83.2; SD 14.8) (P = 0.006). Significant differences were observed between both groups for the domains of burden, eating desire, eating duration, symptoms, food selection, communication and mental health. The results also showed that the dysphagic group had lower symptom score across all symptoms, suggesting higher symptom burdens. CONCLUSIONS: This study is the first to examine QOL and swallow symptoms in palliative care patients with and without dysphagia. Dysphagia causes significantly worse QOL in palliative care patients. Screening for dysphagia and managing its impact on symptoms and QOL domains is important in palliative care.

The Nuts and Bolts of Utilizing Telemedicine in Nursing Homes - The GeriCare@North Experience.

OBJECTIVES: We examined the demographics and the clinical profile of teleconsultations conducted between an acute geriatric medicine department and 8 nursing homes over a period of 6.5 years. DESIGN: This is a prospective, descriptive study. SETTING AND PARTICIPANTS: This study was conducted in 8 nursing homes of Singapore. All nursing home patients referred to the program for teleconsultation between December 2010 and May 2017 were enrolled in the study. MEASURES: The unit observed and studied was the individual telemedicine consultation. Each unique patient contributed 1 or more observation points. The data collected included consultation dates, patient demographics, background medical comorbidities, reasons for referral, physical examination findings, primary diagnoses, and general management plans recommended by the doctors. RESULTS: There were 1673 teleconsultations conducted with 850 unique patients. Most of these patients were categorized as having moderate to severe disability. Ninety-five percent of the consultations were scheduled. The main reasons for referral were for medication review (47.6%) and behavioral problems (22.1%). The 4 commonest comorbidities were hypertension (57.0%), dementia (40.0%), diabetes (39.0%), and hyperlipidemia (38%). The most common primary diagnosis was dementia (21.6%), of which 227 of those diagnosed (62.8%) were referred for behavioral and psychological symptoms of dementia. CONCLUSIONS AND IMPLICATIONS: A telemedicine service for older patients is feasible and could be of a high quality, especially if made available in places where a high density of the latter reside, such as in the care homes and other nursing and rehabilitation facilities.