'Rapid discharge': issues for hospital-based nurses in discharging cancer patients home to die.

AIMS AND OBJECTIVES: To explore issues for hospital-based nurses in arranging rapid home discharge for imminently dying cancer patients in a Singapore acute hospital. BACKGROUND: Dying at home is an important measure of a 'good death'. For hospitalised terminally ill patients, achieving home death can be of paramount importance to them and their family. Nurses experience many challenges in discharging imminently dying cancer patients home, due to time limitations and complex needs of patients and their families. DESIGN: Qualitative interpretive description. METHOD: Using purposive sampling, 14 registered nurses from an oncology ward in a Singapore hospital were recruited to participate in individual, semi-structured interviews. RESULTS: Nursing issues in facilitating rapid discharge fell into three categories: time, discharge processes and family preparation. Decisions to die at home appeared solely family/patient driven, and were made when death appeared imminent. Discharge then became time-critical, as nurses needed to complete multiple tasks within short timeframes. Stress was further exacerbated by nurses' inexperience and the infrequent occurrence of rapid discharge, as well as absence of standardised discharge framework for guidance. Together, the lack of time and discharge processes to enable smooth hospital-to-home transition potentially affected nurses' capacity to adequately prepare families, and may contribute to caregiver anxiety. CONCLUSION: Rapid discharge processes are needed as sudden patient/family decisions to die at home will continue. Earlier involvement of palliative care and implementation of a discharge pathway can potentially help nurses address their multiple responsibilities to ensure a successful transition from hospital to home. RELEVANCE TO CLINICAL PRACTICE: Recognition of nursing issues and challenges during rapid discharge has implications for clinical improvements in supporting nurses during this challenging situation. Results of this study can be used to inform the conceptualisation of clinical interventions to facilitate urgent discharges of imminently dying patients.

Family caregivers of adults with acquired physical disability: Thai case-control study.

This case-control study compares the health of Thai family caregivers of adults with acquired physical disabilities with others without similar responsibilities. To ascertain health perceptions, face-to-face structured interviews using the Short Form (36) were conducted with participants randomly selected from primary care units in eastern Thailand (150 in each group). Despite similar sociodemographic profiles, caregivers reported more health problems and harmful health behaviours. Mean scores for physical and mental health were significantly lower. Factors contributing to poorer health among both caregivers and controls were older age, low educational level, insufficient income and existing health problems. Additional factors for caregivers were gender, spousal or in-law relationship, high dependency, long caregiving time, lack of previous experience and other caregiving responsibilities. This study identifies an urgent need for support to promote caregivers' health to enable them to maintain their vital role.

Management of the acute cardiac patient in the Australian rural setting: a 12 month retrospective study.

BACKGROUND: Rural cardiac patients may require transfer to tertiary health services for ongoing acute cardiac management. The time required to transfer is a consideration in determining appropriate clinical care. There is little published data reporting acute cardiac management in the Australian regional setting that reviews factors determining transfer to a tertiary centre. PURPOSE: This paper reports the findings of a quantitative, retrospective study conducted to identify demographic differences and potential predictors to urban transfer for ongoing acute cardiac management for patients presenting to a regional hospital with suspected acute myocardial infarction. METHODS: Using a purpose designed tool an audit of 204 files from June 2009 to July 2010 was conducted for all patients admitted to a regional hospital having a discharge diagnosis of acute myocardial infarction or angina. Patient demographics, clinical outcomes, concordance with treatment guidelines, and possible predictors of treatment decisions were investigated. FINDINGS: Patients younger than 65 years (p<0.001), unemployed (p<0.01) and with acute electrocardiograph changes (p<0.01) were more likely to be transferred to a tertiary centre. Treatment guidelines concordance for acute cardiac care ranged from 70% to 79% for all patients. CONCLUSIONS: Although presenting patients were treated in a timely manner consistent with national guidelines, to be younger, unemployed or have electrocardiograph changes was a greater predictor to urban transfer. It is unknown if these differences in transferring or not to a tertiary centre contribute to poorer long-term cardiac outcomes for rural patients. Further evaluations are warranted.

Facilitating advance care planning in community palliative care: conversation starters across the client journey.

This paper describes the development of a tool for palliative care nurses to initiate and facilitate advance care planning (ACP) conversations in community palliative care practice. Seven community palliative care services located across Australia participated in a multi-site action research project. Data included participant observation, individual and focus group interviews with palliative care health professionals, and medical record audit. A directed content analysis used a pre-established palliative care practice framework of referral, admission, ongoing management, and terminal/discharge care. From this framework a Conversation Starter Tool for ACP was developed. The Tool was then used in orientation and continuing nurse education programmes. It provided palliative care nurses the opportunity to introduce and progress ACP conversations.

Support interventions for caregivers of physically disabled adults: a systematic review.

In developing countries family caregivers are an important community-based resource who provide care for physically disabled adults. Substantial caregiving commitment is known to adversely affect caregiver health and thereby their capacity to provide ongoing care. This systematic review focused on support interventions for caregivers using Thailand as an example. From 1964 to 2011 international and Thai electronic databases and relevant grey literature were searched. Six English papers and 34 Thai papers published between 1990 and 2010 were found. The Critical Appraisal Skills Programme (CASP) tool was modified to appraise methodological quality. All nurse-led interventions mainly focused on improving caregiving capacity; nearly half considered caregiver health. Only 15 interventions were community-based. Despite variable research quality all studies showed benefits for caregivers, care recipients, and healthcare services. In developing countries without healthy caregivers physically disabled adults would not receive care. There is an urgent need for further investment in community-based research to develop effective interventions designed to promote caregiver health and help them maintain their role.

Tracking the route to sustainability: a service evaluation tool for an advance care planning model developed for community palliative care services.

AIMS AND OBJECTIVES: The study aim was to develop a service evaluation tool for an advance care planning model implemented in community palliative care. BACKGROUND: Internationally, advance care planning programmes usually measure success by completion rate of advance directives or plans. This outcome measure provides little information to assist nurse managers to embed advance care planning into usual care and measure their performance and quality over time. An evaluation tool was developed to address this need in Australian community palliative care services. DESIGN: Multisite action research approach. METHODS: Three community palliative care services located in Victoria, Australia, participated. Qualitative and quantitative data collection strategies were used to develop the Advance Care Planning-Service Evaluation Tool. RESULTS: The Advance Care Planning-Service Evaluation Tool identified advance care planning progress over time across three stages of Establishment, Consolidation and Sustainability within previously established Model domains of governance, documentation, practice, education, quality improvement and community engagement. The tool was used by nurses either as a peer-assessment or self-assessment tool that assisted services to track their implementation progress as well as plan further change strategies. CONCLUSION: The Advance Care Planning-Service Evaluation Tool was useful to nurse managers in community palliative care. It provided a clear outline of service progress, level of achievement and provided clear direction for planning future changes. RELEVANCE TO CLINICAL PRACTICE: The Advance Care Planning-Service Evaluation Tool enables nurses in community palliative care to monitor, evaluate and plan quality improvement of their advance care planning model to improve end-of-life care. As the tool describes generic healthcare processes, there is potential transferability of the tool to other types of services.

Is an advance care planning model feasible in community palliative care? A multi-site action research approach.

AIM: This article reports a study to determine the feasibility of an advance care planning model developed with Australian community palliative care services. BACKGROUND: An effective advance care planning programme involves an organizational wide commitment and preparedness for health service reform to embed advance care planning into routine practice. Internationally, such programmes have been implemented predominantly in aged and acute care with more recent work in primary care. METHODS: A multi-site action research was conducted over a 16-month period in 2007-2009 with three Victorian community palliative care services. Using mixed method data collection strategies to assess feasibility, we conducted a baseline audit of staff and clients; analysed relevant documents (client records, policies, procedures and quality improvement strategies) pre-implementation and post-implementation and conducted key informant interviews (n = 9). SETTINGS AND PARTICIPANTS: Three community palliative care services: one regional and two metropolitan services in Victoria, Australia. RESULTS: The services demonstrated that it was feasible to embed the Model into their organizational structures. Advance care planning conversations and involvement of family was an important outcome measure rather than completion rate of advance care planning documents in community settings. Services adapted and applied their own concept of community, which widened the impact of the model. Changes to quality audit processes were essential to consolidate the model into routine palliative care practice. CONCLUSION: An advance care planning model is feasible for community palliative care services. Quality audit processes are an essential component of the Model with documentation of advance care planning discussion established as an important outcome measure.

Advance care planning in residential aged care facilities.

A person's right to self-determination in health care is now a fundamental principle of health care provision. As a consequence Advance Care Planning (ACP) is a critical issue in health care including palliative care as it is seen as a way of ensuring a person's right to participate not only in future health care choices but in end of life decision making. To date there have been few reports of successful ACP programs. In 2004 and 2005 a program of advance care planning, known as Respecting Patient Choices was introduced in 17 residential aged care facilities in metropolitan Melbourne, Australia. This program consisted of a system-wide approach that included education for aged care staff; information for residents and families as well as changes to organisational processes to ensure that residents have opportunity for self-determination in their future health care. This paper will report on the lessons learnt from this implementation and identify strategies which foster sustainability of ACP.

Managing shame and stigma: case studies of female carers of people with AIDS in southern Thailand.

The authors of this article discuss the effects of shame and stigma on female caregivers of people living with AIDS in southern Thailand. They conducted a longitudinal ethnographic case study over 8 months and collected data using interviews, observations, field notes, and journaling. The authors performed qualitative content analysis and narrative analysis. Public judgment was created in a moral climate, framed by Buddhist precepts of correct and honorable behavior, with different levels of tolerance and stigmatization between men and women. Women caregivers engaged in concealing practices, deception, and withdrawal from social relationships to manage the effects of shame and stigma.

Nurses' moral agency in negotiating parental participation in care.

The purpose of this study was to investigate the issues for nurses in facilitating parental participation in the care of the hospitalized child. A qualitative study informed by grounded theory was undertaken. Nine nurses were recruited from an acute, high-dependency, 23-bed paediatric cardiac/renal unit in Melbourne, Australia. Data collection involved individual semistructured interviews, hospital policies related to family-centred care and a focus group interview. Constant comparative analysis was undertaken to develop an understanding of the data collected in the context of the nurses' experiences and the environment in which they work. Moral agency was identified as the central phenomenon of the study. Causal conditions related to this included the child's best interests, disputes about care and nurses' expectations. These causal conditions were seen to potentially lead to moral distress for the nurses. The coping mechanisms and strategies that affected moral agency have been identified.

Managing family centered palliative care in aged and acute settings.

This paper reports on the management of family centered palliative care in different aged care and acute Australian inpatient settings, following the integration of palliative care with mainstream services. Eighty-eight semistructured interviews were conducted and 425 questionnaires (Palliative Care Practices Questionnaire--PCPQ) were returned, completed from 12 regional and metropolitan locations. Transcribed interviews were analyzed using QSR NVivo and mean PCPQ scores from the four settings were compared. Scores on items from the PCPQ related to family centered care confirmed the analyses. Interviews revealed that factors contributing to the level of support for families offered in the various settings included the core business of the unit; the length of stay of the patients or residents; the acuity or symptom burden; and the coordinated involvement of the multidisciplinary team. Strategies for improving supportive family care are proposed.

Exploring bereavement care in inpatient settings.

This paper compares the attitudes and practices of health professionals to the provision of family-centred bereavement care in different Australian inpatient settings: palliative care services, acute care and long stay residential aged care settings. Semi-structured interviews (88) were conducted with doctors, nurses, pastoral carers and allied health staff. Comprehensive bereavement care was not being provided or resourced in the acute and aged care hospitals to the same level as that provided in palliative care services. Residential care provided continuity of care and good support for grieving relatives and other residents. A structured bereavement program is needed in all inpatient settings with palliative care patients, along with resource and education support for health professionals.

Cultural frameworks of nursing practice: exposing an exclusionary healthcare culture.

Drawing on a feminist praxis study in which nurses were asked to explore their experiences in caring for people of culturally and linguistically diverse backgrounds, cultural frameworks bounded by interconnected markers of race, ethnicity and gender were constructed to analyse the nurses' narrative accounts. The aims of this paper are to discuss the analytical framework that draws on black feminist and postcolonial writers used to examine the cultural constructions of nursing practice. It will also draw attention to one of the major findings of the study in which, through this analytical process, broader connections between health and multicultural government policies, institutional structures and the microcosm of nursing practice were exposed. Through this analysis, an exclusionary whitecentric healthcare culture was exposed, which rendered people of non-English speaking background invisible.

Cultural conflict: the impact of western feminism(s) on nurses caring for women of non-English speaking background.

Much research has been conducted for understanding the health needs of people of different cultural backgrounds and the problems they experience in seeking health care. In Australia, despite such research, it is argued that there remains an exclusionary health care culture that continues to affect equity and access for people of non-English speaking background. There was a need for research in which health professionals examined their own Anglo-Australian culture and its impact on other ethnic communities. Such concerns provided the impetus for a feminist praxis study to engage nurses in understanding and improving care for migrant women. This study was conducted with 26 nurses in a paediatric hospital in Melbourne, Australia. Five collaborative research groups were formed, each consisting of four to six nurses who were co-researchers. Together, the nurses and researchers explored the health care experiences of migrant women, using a variety of quantitative and qualitative data collection strategies. This paper explores a major finding of the study, which was the impact of liberal feminist approaches on the practices of Australian nurses who cared for women of different ethnicity and race. The study found that the efforts of liberal feminist nurses to "treat all people the same" meant that women from different cultural backgrounds did not always receive equity in care. Through the feminist praxis process the nurses were able to explore contradictions in their practice and focus on equity in care to meet the specific gendered and racially constructed needs of women of different cultural backgrounds. A number of strategies were adopted that included regular use of female health interpreters and provision of privacy for migrant women when caring for their children.