Training Health Professions preceptors in rural practices: A challenge for Interprofessional practice and education.

The ever-increasing mandate for interprofessional practice and education (IPE) faces challenges in rural settings. Oregon Health & Science University (OHSU) launched a preceptor development program as part of its commitment to training interprofessional student groups in rural settings. The objectives of the program were to (1) encourage preceptors to exemplify team behaviors; (2) characterize contemporary learners and learning styles of trainees; (3) encourage interprofessional precepting skills, and (4) apply practical teaching tools in the clinical setting. This was a qualitative observational project performed at OHSU rural faculty primary care clinics. Subjects were a convenience sample of rural interprofessional preceptors who volunteered to participate. Each educational session was based on a prior interview identifying their specific training needs. Data analysis was based on results from an evaluation survey and comments from providers at these sites. Key factors such as dedicated time for preceptor development, good communication between the rural practices and the academic health center, and concerns about billing revenue were discovered to be critical to the success of the program.

Species traits affect phenological responses to climate change in a butterfly community.

Diverse taxa have undergone phenological shifts in response to anthropogenic climate change. While such shifts generally follow predicted patterns, they are not uniform, and interspecific variation may have important ecological consequences. We evaluated relationships among species' phenological shifts (mean flight date, duration of flight period), ecological traits (larval trophic specialization, larval diet composition, voltinism), and population trends in a butterfly community in Pennsylvania, USA, where the summer growing season has become warmer, wetter, and longer. Data were collected over 7-19 years from 18 species or species groups, including the extremely rare eastern regal fritillary Speyeria idalia idalia. Both the direction and magnitude of phenological change over time was linked to species traits. Polyphagous species advanced and prolonged the duration of their flight period while oligophagous species delayed and shortened theirs. Herb feeders advanced their flight periods while woody feeders delayed theirs. Multivoltine species consistently prolonged flight periods in response to warmer temperatures, while univoltine species were less consistent. Butterflies that shifted to longer flight durations, and those that had polyphagous diets and multivoltine reproductive strategies tended to decline in population. Our results suggest species' traits shape butterfly phenological responses to climate change, and are linked to important community impacts.

Development of the assessment for collaborative environments (ACE-15): A tool to measure perceptions of interprofessional "teamness".

As interprofessional education moves from classroom to clinical settings, assessing clinical training sites for a high level of "teamness" to ensure optimal learning environments is critical but often problematic ahead of student placement. We developed a tool (Assessment for Collaborative Environments, or ACE), suitable for a range of clinical settings and health professionals, that allows rapid assessment of a clinical practice's teamwork qualities. We collected evidence of tool validity including content, response process, internal structure, and convergent validity. Expert review and cognitive interviews allowed reduction of the initial 30-item tool to 15 items (the ACE-15). Data from 192 respondents from 17 clinical professions and varied clinical settings (inpatient, ambulatory, urban, and rural) were used for factor analysis, which resulted in a single factor solution. Internal consistency reliability Cronbach's alpha was high at 0.91. Subgroup analysis of 121 respondents grouped by their clinical teams (n = 16 teams) showed a wide range of intra-team agreement. Data from a subsequent sample of 54 clinicians who completed the ACE-15 and a measure of team cohesion indicated convergent validity, with a correlation of the tools at r = 0.81. We conclude that the ACE-15 has acceptable psychometric properties and promising utility for assessing interprofessional teamness in clinical training sites that are settings for learners, and, in addition may be useful for team development.

There is no "i" in teamwork in the patient-centered medical home: defining teamwork competencies for academic practice.

Evidence suggests that teamwork is essential for safe, reliable practice. Creating health care teams able to function effectively in patient-centered medical homes (PCMHs), practices that organize care around the patient and demonstrate achievement of defined quality care standards, remains challenging. Preparing trainees for practice in interprofessional teams is particularly challenging in academic health centers where health professions curricula are largely siloed. Here, the authors review a well-delineated set of teamwork competencies that are important for high-functioning teams and suggest how these competencies might be useful for interprofessional team training and achievement of PCMH standards. The five competencies are (1) team leadership, the ability to coordinate team members' activities, ensure appropriate task distribution, evaluate effectiveness, and inspire high-level performance, (2) mutual performance monitoring, the ability to develop a shared understanding among team members regarding intentions, roles, and responsibilities so as to accurately monitor one another's performance for collective success, (3) backup behavior, the ability to anticipate the needs of other team members and shift responsibilities during times of variable workload, (4) adaptability, the capability of team members to adjust their strategy for completing tasks on the basis of feedback from the work environment, and (5) team orientation, the tendency to prioritize team goals over individual goals, encourage alternative perspectives, and show respect and regard for each team member. Relating each competency to a vignette from an academic primary care clinic, the authors describe potential strategies for improving teamwork learning and applying the teamwork competences to academic PCMH practices.

Sampling challenges in nursing home research.

BACKGROUND: Research on end-of-life care in nursing homes is hampered by challenges in retaining facilities in samples through study completion. Large-scale longitudinal studies in which data are collected on-site can be particularly challenging. OBJECTIVES: To compare characteristics of nursing homes that dropped from the study to those that completed the study. METHODS: One hundred two nursing homes in a large geographic 2-state area were enrolled in a prospective study of end-of-life care of residents who died in the facility. The focus of the study was the relationship of staff communication, teamwork, and palliative/end-of-life care practices to symptom distress and other care outcomes as perceived by family members. Data were collected from public data bases of nursing homes, clinical staff on site at each facility at 2 points in time, and from decedents' family members in a telephone interview. RESULTS: Seventeen of the 102 nursing homes dropped from the study before completion. These non-completer facilities had significantly more deficiencies and a higher rate of turnover of key personnel compared to completer facilities. A few facilities with a profile typical of non-completers actually did complete the study after an extraordinary investment of retention effort by the research team. CONCLUSION: Nursing homes with a high rate of deficiencies and turnover have much to contribute to the goal of improving end-of-life care, and their loss to study is a significant sampling challenge. Investigators should be prepared to invest extra resources to maximize retention.

End-of-life care in nursing homes: the high cost of staff turnover.

Nursing home staff turnover results in high cost--both economic and personal--and has a negative impact on the quality of care provided to residents at the end of life. Reducing staff turnover in nursing homes would benefit both the cost to the U.S. health care system, and, most importantly, the care residents receive in the vulnerable period leading to death. There is rising pressure on nursing homes to improve their palliative and end-of-life care practices and reduce transfers to hospital for situations and conditions that can be safely managed on site. Nursing care staff deserve an investment in the specific training necessary for them to give the highest quality care to dying residents. This training should be multifaceted and include the physiological, psychological, spiritual, interpersonal, and cultural (including ethnic) aspects of dying. Empowerment with these necessary knowledge, skills, and attitudes will not only result in better care for residents but likely also will reduce the burnout and frustration staff experience in caring for residents near death.

Quality of care and quality of dying in nursing homes: two measurement models.

BACKGROUND: There is consistent evidence of significant variation in the quality of end-of-life care among nursing homes, with many facilities ill-prepared to provide optimal physical and psychological care that is culturally sensitive and respectful of the needs and preferences of residents and their family members. There is continued evidence that what is impeding efforts to improve care is that most measurement tools are hampered by a lack of distinction between quality of care and quality of dying as well as a lack of complete psychometric evaluation. Further, health services researchers cite the need to include "system-level" factors, variables that reflect leadership, culture, or informal practices, all of which influence end-of-life care and can be used to differentiate one setting from another. The purpose of this article is to report advancement in conceptualizing quality end-of-life care in nursing homes and to offer a refined approach to measurement. METHODS: Two latent constructs are tested: quality of care (composed of system-level factors) and quality of dying (comprised of resident/family outcomes). Data obtained from 85 Midwestern nursing homes and 1282 interviews with bereaved family members were used to evaluate both constructs. RESULTS: Confirmatory factor analyses were conducted and evidence of validity and reliability were obtained for both. CONCLUSION: For health services researchers, expanded models that include system-level factors as well as more comprehensive and psychometrically sound models of resident outcomes stand to inform efforts to improve care in this very important area.

A measure of palliative care in nursing homes.

CONTEXT: Efforts to improve care for nursing home residents stand to be enhanced by measures to assess the degree to which staff provide palliative care. As the incidence of death in nursing homes increases with the aging population, the gap in measurement must be addressed. To that end, we report the development and psychometric testing of a nursing home palliative care survey. OBJECTIVES: The purpose of this study was to evaluate the psychometric properties of the Palliative Care Survey (PCS) for use in nursing homes. METHODS: Psychometric evaluation of the instrument was completed in two phases. Phase 1 focused on individual item analyses and subsequent revision or deletion of items, and Phase 2 evaluated evidence for reliability and validity. Phase 1 included 26 nursing homes and staff (n=717), and Phase 2 included 85 nursing homes and staff (n=2779). Data were analyzed using item-total correlations, Cronbach's alpha, confirmatory factor analysis, and analysis of variance. RESULTS: Support was obtained for a 51-item PCS made up of two constructs, Palliative Care Practice and Palliative Care Knowledge. CONCLUSION: The PCS measures the extent to which the nursing home staff engage in palliative care practices and have knowledge consistent with good end-of-life care. Both practice and knowledge are an essential foundation to providing good end-of-life care to nursing home residents. Efforts to improve care for the dying in nursing homes have been slowed by an absence of measurement tools that capture care processes, a gap that the PCS reported here helps fill.

Embracing quality and safety education for the 21st century: building interprofessional education.

The education of health professions students is rooted historically in time-honored and silo-bound traditions of pedagogy and content not easily influenced by outside forces. However, the quality chasm work of the Institute of Medicine, Institute of Healthcare Improvement, Quality and Safety Education for Nurses, and other groups has led to a remarkable willingness to change at one academic health sciences university. This article describes one university's strategies, challenges, and successes in delivering interprofessional educational programs. Four interprofessional learning activities, developed using a plan-do-study-act model and focused on teamwork, quality, and safety, are presented. Challenges and successes encountered are described as well as a curricular framework to enhance sustainability.

Policy issues in end-of-life care.

The purpose of this policy brief is to bring attention to the urgent systems-level matters that impede progress in improving end-of-life care in the United States. Despite advances in care of the dying over the last 20 years, many recalcitrant system-level barriers prevent high-quality end-of-life care that is consistent with clinical and ethical standards and reasonably adheres to patient and family wishes for care and compassion. A major barrier is the orientation of health care toward rescue medicine despite the fact that most deaths today result from long-standing chronic disease. Recommendations for policy changes are suggested, and nursing's role in advocating for policy change is explored.

Men as caregivers at the end of life.

BACKGROUND: Few studies have focused on men as caregivers at the end-of-life. The objective of this secondary data analysis was to examine the experiences of men involved in end-of-life caregiving, focusing on caregiver strain. METHODS: We used a random sample of Oregon death certificates to telephone survey family caregivers of Oregonians who had died 2 to 5 months earlier in private homes, nursing homes, and other community-based settings. Measurements included single-item indicators and embedded scales to measure caregiver strain and perceived decedent symptom distress. For the 25 husbands, sons, wives, and daughters who reported the highest levels of strain, we also analyzed caregivers' description of the decedent's last few days of life. RESULTS: The sample included 1384 caregiver interviews from a pool of 3048 death certificates. Men constituted 29% of the caregivers, including 15% sons, 9% husbands, and 5% others. In a linear regression model, male gender was a significant predictor of lower caregiver strain (p < 0.001). The strongest predictor of high end-of-life caregiver strain was the severity of the decedents' symptom distress. The qualitative analysis revealed that men used fewer words than women did to describe their experiences, and, despite subsequently reporting the highest levels of caregiving strain, only 15% of men spontaneously mentioned their own struggles. CONCLUSIONS: As caregivers at the end of life, men are less common and less likely to report caregiver strain and decedent symptom distress. Health care professionals should actively ask men about these issues and listen carefully, as their responses may be brief and understated.

Increased family reports of pain or distress in dying Oregonians: 1996 to 2002.

The aim of this study was to compare the prevalence of family-reported pain or distress during the last week of decedents' lives during two times: November 1996 to December 1997 and June 2000 to March 2002. We telephone-surveyed family caregivers of Oregonians who had died 2 to 5 months previously in private homes, nursing homes, and other community-based settings. Caregivers were asked to rate the level of pain or distress during the decedent's final week of life on a four-point scale. Data were collected from 340 respondents from 1996-1997 and 1384 respondents from 2000-2002. We found that the prevalence of family-reported moderate or severe pain or distress (compared to comfortable or mild pain or distress) in Oregon decedents increased from 30.8% in 1996-1997 to 48% in 2000-2002. Using a logistic regression model to control for differences between the two sampling times and other predictors of increased pain or distress, decedents in 2000-2002 remained approximately twice as likely to be reported to be in moderate or severe pain or distress during the last week of their lives (Time 2 vs. Time 1, odds ratio [OR] 2.09, 95% confidence interval [CI] 1.59-2.74). We discuss possible explanations for this finding, including media effect created by the publicity surrounding the second ballot measure and subsequent availability of physician-assisted suicide in November 1997. Alternatively, trends in under funding and under staffing of hospice and community nursing resources may have disproportionately affected care in the final week of life, which depends heavily on skilled nursing care for effective symptom control and psychosocial support of the patient and family.

Family perceptions of worry, symptoms, and suffering in the dying.

In this exploratory study, family members of 63 decedents were interviewed by telephone, two to five months post-death, about their perceptions of their loved one's worries, symptoms, and suffering at the end of life. The most common worries reported focused on loss of bodily function (44%), being dependent (40%), and being a burden (39%). Distressing physical and psychological symptoms were reported. A majority (94%) of family members reported that their loved one suffered at the end of life, but only worries about loss of quality of life (e.g., being unable to participate in enjoyable activities) were predictive of reports of suffering. Findings suggest that worries, irrespective of the level of current symptoms, play an important role in the suffering of dying patients, and that treatment plans for the terminally ill should routinely explore both symptoms and worries.

Out-of-hospital death: advance care planning, decedent symptoms, and caregiver burden.

OBJECTIVES: To examine the end-of-life experiences of elderly decedents dying out of the hospital and their family caregivers in a state in which the vast majority of Medicare deaths occur in community settings. DESIGN: Telephone survey of family caregivers 2 to 5 months after decedents' deaths. SETTING: Statewide (Oregon) random sample of death certificates. PARTICIPANTS: One thousand one hundred eighty-nine family caregivers of decedents aged 65 and older who died of natural deaths in community settings between 2000 and 2002. MEASUREMENTS: A 69-item telephone questionnaire with single-item indicators and embedded scales that indexed advance directives, use of life-sustaining treatments, hospice enrollment, decedent symptom experience and perceived distress, family financial hardship, out-of-pocket expenses, and caregiver strain. RESULTS: Most decedents had advance directives (78.3%) and were enrolled in hospice (62.4%). Although perceived decedent symptom distress was low overall, certain symptoms (e.g., pain, dyspnea, constipation) were distressing for approximately half of decedents experiencing them. Financial hardship, out-of-pocket expenses, and caregiver strain were frequently reported. American Indian race and younger age were associated with decedent symptom distress. Greater perceived decedent symptom distress, hospice enrollment, more caregiver involvement, and more financial burden were associated with greater caregiver strain. CONCLUSION: Despite high rates of advance directives and hospice enrollment, perceived symptom distress was high for a subset of decedents, and caregiver strain was common. As location of death increasingly shifts nationwide from hospital to community, unmet decedent and family needs require new clinical skills and healthcare policies.

Trends in opioid use over time: 1997 to 1999.

Substantial resources have been spent to improve pain control for dying patients, and increased opioid administration has been presumed. Oregon has been a consistent leading state in per capita use for morphine for the past 10 years, as recorded by the Automation of Reports and Consolidated Orders System (ARCOS). Health policy experts, extrapolating from World Health Organization methods, have suggested these data are indicative of the quality of end-of-life care in Oregon. To determine whether trends in opioid prescription at the state and national levels reflect increased opioid use for inpatients during the final week of life, chart reviews were conducted to record all opioid medications administered in the last week of life to 877 adult inpatients who died from natural causes between January 1, 1997 and December 31, 1999. Inpatient morphine use did not increase significantly for dying patients from 1997 to 1999. However, overall morphine use for both Oregon and the United States as measured by ARCOS data increased significantly. Comparisons revealed no significant difference between linear trends for Oregon and U.S. morphine use, but both were significantly greater than the dying inpatients. This pattern was also found for all other opioids. These findings suggest that ARCOS data do not necessarily provide information about opioid use for specific subpopulations of patients and raise questions about the meaning of observed increases in ARCOS data.

Complementary and alternative therapy use at end-of-life in community settings.

OBJECTIVE: To investigate the prevalence of complementary and alternative medicine (CAM) use by an end-of- life population. DESIGN: Random selection of death certificates used to locate family caregivers who were interviewed by telephone 2-5 months following decedents' deaths. PARTICIPANTS: Decedent subjects died of natural causes in community settings. Family caregivers were very involved in the care and decision making for decedents during their terminal illness. MEASURE: Family caregivers reported on whether decedents had used CAM, type of modality, and motivation for use. RESULTS: CAM use by decedents was reported by 53.7% of family caregivers. Decedents who had used CAM were more likely to be younger, to have college degrees and higher household incomes, and to have used one or more life-sustaining treatment. The most frequent reason the decedents had used CAM was for symptom relief. CONCLUSIONS: As baby boomers age, bringing their CAM familiarity and previous practices into the end-of-life phase, clinicians will need to be aware that CAM use for symptom control is likely to be prevalent.