Preconception care for women with diabetes: the midwife's role

Diabetes mellitus is a chronic illness which affects a significant number of childbearing women. Despite the potential for adverse consequences for both maternal and fetal wellbeing, few women with diabetes plan their pregnancies to ensure that they enter pregnancy in optimal health. Furthermore, whilst adverse pregnancy outcomes are well documented for women with type I diabetes, it is now apparent that an increasing number of women with type II diabetes are becoming pregnant with similar adverse associated risk. There is an increasing recognition that significant adverse pregnancy outcomes are determined prior to a woman initiating pregnancy care, many of which could be minimised with the introduction of preconception care. As formalised preconception care clinics remain scant across the United Kingdom, there is an urgent need to increase the opportunities for the provision of preconception care and advice to women with diabetes. Midwives are ideally placed to provide preconception advice to women and could provide the missing link in terms of preconception advice for women with diabetes.

Improving clinician self-efficacy does not increase asthma guideline use by primary care clinicians

Objective: The purpose of this study was to show the association between changes in clinician self-efficacy and readiness to change and implementation of an asthma management program (Easy Breathing). Methods: A 36 month randomized, controlled trial was conducted involving 24 pediatric practices (88 clinicians). Randomized clinicians received interventions designed to enhance clinician self-efficacy and readiness to change which were measured at baseline and 3 years. Interventions consisted of an educational toolbox, seminars, teleconferences, mini-fellowships, opinion leader visits, clinician-specific feedback, and pay for performance. The primary outcome was program utilization (number of children enrolled in Easy Breathing/year); secondary outcomes included development of a written treatment plan and severity-appropriate therapy. Results: At baseline, clinicians enrolled 149 ± 147 (mean ± SD) children/clinician/year; 84% of children had a written treatment plan and 77% of plans used severity-appropriate therapy. At baseline, higher self-efficacy scores were associated with greater program utilization (relative rate [RR], 1.34; 95% confidence interval [CI], 1.04-1.72; P =.04) but not treatment plan development (RR, 0.63; 95% CI, 0.29-1.35; P =.23) or anti-inflammatory use (RR, 1.76; 95% CI, 0.92-3.35; P =.09). Intervention clinicians participated in 17 interventions over 36 months. At study end, self-efficacy scores increased in intervention clinicians compared to control clinicians (P =.01) and more clinicians were in an action stage of change (P =.001) but these changes were not associated with changes in primary or secondary outcomes. Conclusions: Self-efficacy scores correlated with program use at baseline and increased in the intervention arm, but these increases were not associated with greater program-related activities. Self-efficacy may be necessary but not sufficient for behavior change. Copyright © 2012 by Academic Pediatric Association.

A shared care model pilot for palliative home care in a rural area:Impact on symptoms, distress, and place of death

Context: Shared care models integrating family physician services with interdisciplinary palliative care specialist teams are critical to improve access to quality palliative home care and address multiple domains of end-of-life issues and needs. Objectives: To examine the impact of a shared care pilot program on the primary outcomes of symptom severity and emotional distress (patient and family separately) over time and, secondarily, the concordance between patient preferences and place of death. Methods: An inception cohort of patients (n = 95) with advanced, progressive disease, expected to die within six months, were recruited from three rural family physician group practices (21 physicians) and followed prospectively until death or pilot end. Serial measurement of symptoms, emotional distress (patient and family), and preferences for place of death was performed, with analysis of changes in distress outcomes assessed using t-tests and general linear models. Results: Symptoms trended toward improvement, with a significant reduction in anxiety from baseline to 14 days noted. Symptom and emotional distress were maintained below high severity (7-10), and a high rate of home death compared with population norms was observed. Conclusion: Future controlled studies are needed to examine outcomes for shared care models with comparison groups. Shared care models build on family physician capacity and as such are promising in the development of palliative home care programs to improve access to quality palliative home care and foster health system integration. © 2011 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.

Identifying research priorities on infections in older adults:Proceedings of an interdisciplinary workshop

Background: Infections pose a substantial burden to the health of older adults. In this report, we describe the proceedings of a workshop to formulate and prioritize research questions about infections in older adults using an interdisciplinary approach. Methods: Researchers from four sectors (basic science, clinical sciences, health services and epidemiology/determinants of health) and representatives from various Canadian local, provincial, and federal stakeholder groups were invited to a two-day workshop. Five multi-disciplinary groups and stakeholders from each of three healthcare settings (long term, acute care and community) discussed research priorities for each of the settings. Five to ten research questions were identified for each setting. Results: The research questions proposed ranged from risk factors and outcomes for different infections to the effect of nutrition on infection and the role of alternative and complementary medicine in treating infections. Health service issues included barriers to immunization, prolongation of hospital length of stay by infection, use of care paths for managing infections, and decision-making in determining the site of care for individuals with infections. Clinical questions included risk factor assessment for infection, the effectiveness of preventative strategies, and technology evaluation. Epidemiologic issues included the challenge of achieving a better understanding of respiratory infections in the community and determining the prevalence of colonization with multi-resistant bacteria. Conclusions: The questions are of direct relevance to researchers in a wide variety of fields. Bringing together a multi-disciplinary group of researchers to frame and prioritize research questions about aging is feasible, participants valued the opinions of people working in other areas.

Palliative care nursing in rural and urban community settings:A comparative analysis

Nurses have key roles in the coordination and delivery of community-based palliative care. The purpose of this study was to examine the differences between rural and urban community nurses' delivery of palliative care services. A survey was distributed to 277 nurses employed by a community agency in Ontario, Canada, and a 60% response rate was obtained. Nurses reported spending 27% of their time providing palliative care. Rural and urban nurses had similar roles in palliative care but rural nurses spent more time travelling and were more confident in their ability to provide palliative care. Both groups of nurses reported moderate job satisfaction and moderate satisfaction with the level of interdisciplinary collaboration in their practice. Several barriers to and facilitators of optimal palliative care provision were identified. The study results provide information about the needs of nurses that practise in these settings and may provide a basis for the development of strategies to address these needs.

Optimizing Research on End-of-Life Care for Seniors:The Collective New Emerging Team on End of Life Care for Seniors University of Ottawa, Institute of Palliative Care

Background: End-of-life care for seniors is an important and neglected area of research. The University of Ottawa Institute of Palliative Care has expanded its research capacity by developing a Canadian Institutes of Health Research (CIHR) funded new emerging team on end-of-life care for seniors. This initiative brings together an interdisciplinary team of researchers from palliative care and geriatrics to develop a comprehensive program of research. Methods: 1) A variety of investigators from the fields of palliative care and geriatrics and disciplines of epidemiology, medicine, nursing, psychology and social work will collaborate on the development of a research agenda focussed on end-of-life care for seniors. 2) The conceptual model for the research program consists of 4 broad interrelated domains that are congruent with the CIHR themes of health services, clinical issues, population health and psychosocial, cultural, spiritual and ethical issues; this framework will guide the research program and all studies emanating from the program. 3) Research studies will focus on 5 areas of inquiry that are central to end-of-life care for seniors: palliative end-of-life care for rural seniors, care settings, burden, role of volunteers, and delirium. Results: This new team has the potential to obtain peer-reviewed funding, recruit and train a new generation of researchers, and build a network of concerned researchers. Conclusions: The new team should ultimately contribute to an improved quality of care for seniors who are approaching death.

Professionals delivering palliative care to people with COPD: qualitative study

This article describes health and social care professionals' perceptions of palliative care and facilitators and barriers to the delivery of such care for patients with advanced chronic obstructive pulmonary disease. Health professionals participated in semi structured interviews and focus groups which were analysed using content analysis. According to participants, care of patients with chronic obstructive pulmonary disease is focused upon the management of symptoms, with emphasis focused predominately on an acute model of care. Key barriers towards the delivery of palliative care included the reluctance to negotiatie end-of-life decisions and a perceived lack of understanding among patients and carers regarding the illness trajectory. Consequently the delivery of palliative care was viewed as a specialist role rather than an integral component of care. There is a need for education and training for health and social care professions to plan and provide high quality end-of-life care.

Testing a model for developing, implementing and evaluating a strategy to improve the quality of nursing and midwifery care in an acute hospital trust.

Abstract:
Background: Health care organisations
worldwide are faced with the need to develop
and implement strategic organisational plans
to meet the challenges of modern health care.
There is a need for models for developing, implementing and evaluating strategic plans that engage practitioners, and make a measurable difference to the patients that they serve. These presentations describe the development, implementation and evaluation of such a model by a team of senior nurses and practice developers, to underpin a strategy for nursing and midwifery in an acute hospital trust. Developing a Strategy The PARIHS (Promoting Action on Research Implementation in Health Services) conceptual framework (Kitson et al, 1998) proposes that successful implementation of change in practice is a function of the interplay of three core elements: the level of evidence supporting the proposed change; the context or environment in which the change takes place, and the way in which change is facilitated. We chose to draw on this framework to develop our strategy and implementation plan (O’Halloran, Martin and Connolly, 2005). At the centre of the plan are ward managers. These professionals provide leadership for the majority of staff in the trust and so were seen to be a key group in the implementation process.

A Pilot Evaluation of the Palliative Performance Scale in Long Term Care: Tips for Success

Aims: Palliative care in long-term care (LTC) homes is an area of growing concern. Little work has been done to explore innovative ways to identify and care for residents who become palliative. The purpose of this intervention study was to evaluate the implementation of the Palliative Performance Scale (PPS) in LTC. Specifically we explored staff perceptions about implementing the PPS and how it cued staff to initiate palliative care discussion with residents and family when a resident’s health declined.

Methods: This study utilized a qualitative descriptive design that included data from four separate sources: journals of three ‘champions’ who were responsible for leading the implementation of the PPS; staff evaluations of three educational training sessions; minutes from meetings; and 11 interviews from key staff who were involved in the implementation process. Data were analyzed using thematic content analysis.

Results: Staff generally felt positively about using the PPS in LTC and stated that it increased awareness of palliative care and helped identify those residents who were nearing the end of life. There were some barriers to implementing it, such as staff resistance and lack of time to complete it. The importance of having a designated ‘champion’ and effective interdisciplinary communication in addition to widespread training, were identified as successful strategies to facilitate the implementation process.

Conclusion: These study findings support the use of the PPS in LTC and offer some perspective about ways to implement it successfully. Future work is needed to evaluate the PPS in LTC using more rigorous designs.

Perceptions of the Nurse Practitioner Role in Facilitating the Implementation of an Onsite Pain Management Team in Long Term Care

Background: One strategy to improve pain management in long term care (LTC) is to optimize the emerging role of the nurse practitioner (NP) in LTC. The purpose of this sub study was to learn about the NP role in implementing an onsite, interdisciplinary Pain Team in the LTC home setting.

Methods: We used a case study design that included two NPs who worked at separate LTC homes. Each of the NPs completed a weekly questionnaire of pain-related activities that they engaged in over a one-year implementation period; and a diary, using critical reflection, about their experiences and strategies used to implement the Pain Team. Descriptive statistics and thematic content analysis were used to analyze the case study data.

Findings: NPs tended to be most engaged in pain assessment and collaborated more with licensed nurses and personal support workers; less with pharmacists. NPs were more involved in organizational level activities, such as participating in committee work or assisting with the development of policies and procedures about pain. NPs created palliative care and pain service protocols; engaged in policy development, in-servicing, quality assurance and advocacy; and encouraged best practices. NPs were challenged with time constraints for pain management and balancing other role priorities and felt that increased scope of practice for them was needed.

Conclusions: The results of this study highlight how NPs implemented a Pain Team in LTC which may be helpful to others interested in implementing a similar strategy to reduce residents’ pain.

Building capacity in palliative care for personal support workers in long-term care through experiential learning

Background

Providing palliative care in long-term care (LTC) homes is an area of growing importance. As a result, attention is being given to exploring effective palliative care learning strategies for personal support workers (PSWs) who provide the most hands-on care to LTC residents.

The purpose of this intervention was to explore hospice visits as an experiential learning strategy to increase the capacity of PSWs in palliative care, specifically related to their new learning, and how they anticipated this experience changed their practices in LTC.

This study utilised a qualitative descriptive design.

Eleven PSWs from four Ontario LTC homes were sent to their local hospice to shadow staff for one to two days. After the visit, PSWs completed a questionnaire with open-ended questions based on critical reflection. Data were analysed using thematic content analysis.

PSWs commented on the extent of resident-focused care at the hospice and how palliative care interventions were tailored to meet the needs of residents. PSWs were surprised with the lack of routine at the hospice but felt that hospice staff prioritised their time effectively in order to meet family and client care needs. Some PSWs were pleased to see how well integrated the PSW role is on the community hospice team without any hierarchical relationships. Finally, PSWs felt that other LTC staff would benefit from palliative care education and becoming more comfortable with talking about death and dying with other staff, residents and family members.

This study highlighted the benefits of PSWs attending a hospice as an experiential learning strategy. Future work is needed to evaluate this strategy using more rigorous designs as a way to build capacity within PSWs to provide optimal palliative care for LTC residents and their family members.

PSWs need to be recognised as important members within the interdisciplinary team. PSWs who shadow staff at hospices view this experience as a positive strategy to meet their learning needs related to palliative care.

The character of behavioural symptoms on admission to three Canadian long-term care homes

Objectives: We determined the prevalence and nature of behavioural symptoms at the time of admission to a long-term care home (LTCH) and occurrence of resident-to-resident aggressive behaviour associated with behavioural symptoms within three months following admission. Method: The Cohen-Mansfield Agitation Inventory and Aggressive Behaviour Scale were completed at the time residents were admitted into the LTCH. A chart review, conducted three months after admission into the LTCH, abstracted documented resident-to-resident aggression. Three LTCHs located in Ontario, Canada participated in the study. Results: During a 16-month period, 339 individuals admitted to the LTCHs comprised the study sample. A comparison was made between residents with and without dementia. At admission, residents with dementia had a greater number of behavioural symptoms than those without dementia (mean = 3.79, SD = 3.32 versus mean = 2.56, SD = 2.24, respectively; t(200) = 1.91; p = 0.059). Residents with and without dementia exhibited similar behaviours but differed on the prevalence of these behaviours. The most frequently reported behavioural symptoms for residents in both groups were verbal agitation and non-aggressive physical behaviours. The most frequently recorded aggressive behaviour for all residents was resisting care. In the three months post admission, 79 (23%) residents were involved in a documented incident that involved aggressive behaviour to another resident. Conclusion: A standardized comprehensive assessment for admission to a LTCH is an important strategy that can be used to identify behavioural symptoms and plan appropriate care management. 

Factors affecting the successful implementation and sustainability of the Liverpool Care Pathway for dying patients – a realist evaluation

Objectives: The Liverpool Care Pathway for the dying patient (LCP) was designed to improve end-of-life care in generalist health care settings. Controversy has led to its withdrawal in some jurisdictions. The main objective of this research was to identify the influences that facilitated or hindered successful LCP implementation.

Method: An organisational case study using realist evaluation in one health and social care trust in Northern Ireland. Two rounds of semi-structured interviews were conducted with two policy makers and twenty two participants with experience and/or involvement in management of the LCP during 2011 and 2012.

Results: Key resource inputs included facilitation with a view to maintaining LCP ‘visibility’, reducing anxiety among nurses and increasing their confidence regarding the delivery of end-of-life care; and nurse and medical education designed to increase professional self-efficacy and reduce misuse and misunderstanding of the LCP. Key enabling contexts were consistent senior management support; ongoing education and training tailored to the needs of each professional group; and an organisational cultural change in the hospital setting that encompassed end-of-life care.

Conclusion: There is a need to appreciate the organizationally complex nature of intervening to improve end-of-life care. Successful implementation of evidence-based interventions for end-of-life care requires commitment to planning, training and ongoing review that takes account of different perspectives, institutional hierarchies and relationships and the educational needs of professional disciplines. There is a need also to recognise that medical consultants require particular support in their role as gatekeepers and as a lead communication channel with patients and their relatives.

Integrated care pathways for airway diseases (AIRWAYS-ICPs)

The objective of Integrated Care Pathways for Airway Diseases (AIRWAYS-ICPs) is to launch a collaboration to develop multi-sectoral care pathways for chronic respiratory diseases in European countries and regions. AIRWAYS-ICPs has strategic relevance to the European Union Health Strategy and will add value to existing public health knowledge by: 1) proposing a common framework of care pathways for chronic respiratory diseases, which will facilitate comparability and trans-national initiatives; 2) informing cost-effective policy development, strengthening in particular those on smoking and environmental exposure; 3) aiding risk stratification in chronic disease patients, using a common strategy; 4) having a significant impact on the health of citizens in the short term (reduction of morbidity, improvement of education in children and of work in adults) and in the long-term (healthy ageing); 5) proposing a common simulation tool to assist physicians; and 6) ultimately reducing the healthcare burden (emergency visits, avoidable hospitalisations, disability and costs) while improving quality of life. In the longer term, the incidence of disease may be reduced by innovative prevention strategies. AIRWAYSICPs was initiated by Area 5 of the Action Plan B3 of the European Innovation Partnership on Active and Healthy Ageing. All stakeholders are involved (health and social care, patients, and policy makers).