Family carers' experiences regarding patient transfers between care settings in palliative care: an interview study.

BACKGROUND: To understand how family carers experienced the illness trajectory of their next of kin related to transfers taken place between care settings in palliative care, their experiences and attitude regarding the transfer decision and their experiences regarding patient transfers across settings. METHODS: Semi-structured interviews were held with 21 family carers. A constant comparative approach was used to analyze data. RESULTS: Three themes were identified after data analysis: (I) patient transfer dynamics, (II) experiences regarding the changed care environment and (III) impact of the transfer on the family carer. The dynamics of the patient's transfer were affected by the balance between the care provision (professional and informal care) and the changes in the patient's needs. Experiences regarding patient transfers strongly varied depending on the setting and were based on the personnel's conduct and the quality of receiving information. Study results revealed shortcomings in perceived inter-professional communication and continuity of information during a patient's hospitalization. Concomitant feelings of relief, anxiety or feeling insecure could arise in situations of a patient's transfer. CONCLUSIONS: This study highlighted the adaptability of family carers when caring for their next of kin with palliative care needs. To support carers in coping with their role as caregivers and to share the responsibility of caregiving, involved healthcare professionals should timely evaluate family carers' preferences and needs and adapt the care organization accordingly. A pro-active attitude, which anticipates on the possibility of an impending decompensation of the family carer, is recommended. When the decision for a patient's transfer is taken, multiple factors influenced the choice of the care setting. Healthcare professionals need to take these factors into account when discussing, with patients and carers, the need for a transfer. Continuity of information can be improved. Further development and evaluation of interventions, aimed at improving informational continuity can be recommended.

Patients' experiences of transfers between care settings in palliative care: an interview study.

BACKGROUND: Palliative patients often suffer from serious illness and commonly move between care settings. As such, transfers of patients can take place between acute hospital based care and community based care in both directions. The involvement of multiple caregivers providing care across settings causes fragmentation of care. To address this challenge and to optimize coordination and continuity of care, we explored experiences of palliative patients regarding their transfers between care settings and the perceived role of the treating family physician. METHODS: Qualitative interview study of 20 palliative patients. Participating settings were the hospital and hospitals' palliative care unit, the nursing home, the home care setting and the palliative day care centre. A constant comparative method was used to analyze data. RESULTS: Although the home was considered the preferred residence, perceptions of unsafety arose in cases of increased symptom burden and when the organization of home care was insufficiently geared to the patients' needs. Both the nursing home and the palliative care unit offered safety and good care when home residence became unfeasible. Upon hospital admission, experiences did not always meet expectations, varying significantly depending on the hospital, type of ward and reason for hospitalization. Perceived issues regarding hospital discharge were premature release, lack of seamless care and home care insufficiently tailored to the patients' needs. The family physician's role assignment ranged from pivotal to minimal. Patients especially expected their family physician to guarantee continuity of care. CONCLUSIONS: Home is considered the preferred place of long-term care, as long as it is perceived a safe environment. A person-centered approach, focusing on the patient's complex needs, is not consistently implemented in palliative care settings. Barriers in inter-professional collaboration need to be tackled to provide high quality care across settings.

Healthcare professionals' experiences of inter-professional collaboration during patient's transfers between care settings in palliative care: A focus group study.

BACKGROUND: Continuity of care is challenging when transferring patients across palliative care settings. These transfers are common due to the complexity of palliative care, which has increased significantly since the advent of palliative care services. It is unclear how palliative care services and professionals currently collaborate and communicate to ensure the continuity of care across settings, and how patient and family members are involved. AIM: To explore healthcare professionals' experiences regarding the communicative aspects of inter-professional collaboration and the involvement of patient and family members. DESIGN: Qualitative design, including focus group discussions. SETTING/PARTICIPANTS: The study focused on one palliative care network in Belgium and involved all palliative care settings: hospital, hospital's palliative care unit, home care, nursing home. Nine group discussions were conducted, with diverse professionals (n = 53) from different care settings. RESULTS: Timely and effective inter-professional information exchange was considered fundamental. A perceived barrier for interprofessional collaboration was the lack of a shared electronic health record. Efficiency regarding multidisciplinary team meetings and inter-professional communication were subject to improvement.A striking study finding was the perceived insufficient open communication of specialists towards patients and the lack of shared decision making. This not only hampered advance care planning discussions and early integration of palliative home care, but also the functioning of other professionals. CONCLUSION: From the perspective of the integrated care framework, several areas of improvement on different levels of care and collaboration are identified. Support from policymakers and researchers is required to achieve integrated palliative care in regional networks.

Interprofessional collaboration within fluid teams: Community nurses' experiences with palliative home care.

AIMS AND OBJECTIVES: To explore how community nurses experience the collaboration with general practitioners and specialist palliative home care team nurses in palliative home care and the perceived factors influencing this collaboration. BACKGROUND: The complexity of, and the demand for, palliative home care is increasing. Primary palliative care is provided by community nurses and general practitioners, often in collaboration with palliative home care team nurses. Although these professionals may each individually be part of a fixed team, a new temporary team is often composed for every new palliative patient. These membership changes, referred to as team membership fluidity, challenge professionals to work effectively. DESIGN AND METHODS: A qualitative research design, using semi-structured interviews with community nurses. Participant selection happened through regional palliative care networks in Belgium. The network's palliative home care team nurses selected community nurses with whom they recently collaborated. Twenty interviews were conducted. A constant comparative analysis approach was used. Consolidated criteria for reporting qualitative research guidelines were followed. RESULTS: Formal interprofessional team meetings were not common practice. The other's approachability and knowing each other positively influenced the collaboration. Time constraints, the general practitioners' lack of expertise, communication style, hierarchy perception and income dependency negatively influenced the collaboration with general practitioners and determined palliative home care team nurses' involvement. The coping strategies of community nurses balanced between a behaviour focused to the patient and to the professional relationship. Specialist palliative home care team nurses were relied upon for their expertise but also to mediate when community nurses disagreed with general practitioners. CONCLUSION: Community nurses showed to be highly adaptable within the fluid team. Strikingly, dynamics described in the doctor-nurse game 50 years ago are still present today and affect the interprofessional communication. Interprofessional education interventions can contribute to improved interprofessional collaboration. RELEVANCE TO CLINICAL PRACTICE: The study findings uncovered critical knowledge gaps in interprofessional collaboration in palliative home care. Insights are relevant for and related to professional well-being and workplace learning.

Developing the International Association for Communication in Healthcare (EACH) to address current challenges of health communication.

In 2017, EACH celebrated its change of name from European Association for Communication in Healthcare to EACH: International Association for Communication in Healthcare. This paper aims to present the developments and achievements of EACH over the past five years with a focus on its mission in promoting and advancing the field of communication in healthcare. Specifically, the paper focuses on how EACH, first, promotes research in the field of health communication, second, provides support, resources and sharing for healthcare communication teachers and, third, aims at influencing policy through dissemination of evidence. This paper also explores future challenges and directions for EACH to further strengthen its impact by designing activities in knowledge transfer and knowledge dissemination, engaging with patients and truly benefitting from their expertise, fostering active participation and networking among its members, targeting interventions to the needs of different countries around the world and refining knowledge-sharing and cooperation both within the membership of EACH and outside the association to as wide an audience as possible. Scholars, educators and practitioners active in the field of healthcare communication are invited to comment on this paper and to actively contribute towards the goals of EACH.

Determinants of physician-patient communication: The role of language, education and ethnicity.

AIM: The value of patient-centredness, of which effective physician-patient communication is one key element, has been established within medicine. However, research shows social differences in medical communication according to the patient's social background. This study examines the role of the patient's ethnicity, educational background and language proficiency in relation to physician-patient interaction in 31 countries. METHOD: More than fifty thousand patients were given a standardized questionnaire to gain insights into the professional behaviour of their family physician and their own expectations and actions. RESULTS: While no effect of ethnicity was found, there was a significant effect of patients' language proficiency and educational level. Patients with lower language proficiencies were more likely to experience more negative interactions with their physicians. Second-generation migrants who did not fill in the questionnaire in an official language were more negative about the patient-physician interaction. Patients who had a greater chance of having a positive patient-physician interaction were more likely to be higher educated. CONCLUSION: Despite the shift towards patient-centred care in medicine, physician-patient communication is still determined by the patient's educational background and language proficiency. PRACTICE IMPLICATION: GPs should primarily be trained to tailor their communication styles to match patients' backgrounds.

Rethinking End-of-Life Care and Palliative Care: Learning From the Illness Trajectories and Lived Experiences of Terminally Ill Patients and Their Family Carers.

Lynn conceptualized end-of-life (EoL) care for patients with advanced chronic-progressive illnesses as a combination of life-preserving/palliative care, the palliative aspect gradually becoming the main focus as death approaches. We checked this concept by exploring the advanced-terminal illness trajectories of 50 patients. Strategies heralding active therapy exhaustion were the catalyst for a participant's awareness of terminality, but were not a decisive factor in the divergent EoL care pathways we detected. The terms life-preserving and palliative do not adequately capture EoL care pathways due to their conceptual ambiguity. Conversely, the concept of EoL care encompassing three palliative care modalities ( life-prolonging palliative therapy, restorative palliative care, and symptom-oriented [only] palliative care), each harboring a different blend of life-preserving and symptom-comforting aspects, proved adequate. These modalities could run serially, oscillatorily, or parallelly, explaining the divergent EoL care pathways. We suggest an adjustment of the model of Lynn and reconsider the traditional palliative care concept.

Process Evaluation of an eHealth Intervention Implemented into General Practice: General Practitioners' and Patients' Views.

(1) Background: It has been shown that online interventions can be enhanced by providing additional support; accordingly, we developed an implementation plan for the use of an eHealth intervention targeting physical activity and healthy nutrition in collaboration with general practitioners (GPs). In this study, GPs and patients evaluated the actual implementation; (2) Methods: Two hundred and thirty two patients completed the feasibility questionnaire regarding the implementation of "MyPlan 1.0" in general practice. Individual interviews were conducted with 15 GPs who implemented "MyPlan 1.0" into their daily work flow; (3) Results: The majority of the patients indicated that general practice was an appropriate setting to implement the online intervention. However, patients were not personally addressed by GPs and advice/action plans were not discussed with the GPs. The GPs indicated that this problem was caused by the severe time restrictions in general practice. GPs also seemed to select those patients who they believed to be able to use (e.g., highly educated patients) and to benefit from the intervention (e.g., patients with overweight); (4) Conclusions: Although GPs were involved in the development of the online intervention and its implementation plan, the programme was not used in general practice as intended.

Workplace learning through collaboration in primary healthcare: A BEME realist review of what works, for whom and in what circumstances: BEME Guide No. 46.

BACKGROUND: Changes in healthcare practice toward more proactive clinical, organizational and interprofessional working require primary healthcare professionals to learn continuously from each other through collaboration. This systematic review uses realist methodology to consolidate knowledge on the characteristics of workplace learning (WPL) through collaboration by primary healthcare professionals. METHODS: Following several scoping searches, five electronic bibliographic databases were searched from January 1990 to December 2015 for relevant gray and published literature written in English, French, German and Dutch. Reviewers worked in pairs to identify relevant articles. A set of statements, based on the findings of our scoping searches, was used as a coding tree to analyze the papers. Interpretation of the results was done in alternating pairs, discussed within the author group and triangulated with stakeholders' views. RESULTS: Out of 6930 references, we included 42 publications that elucidated who, when, how and what primary healthcare professionals learn through collaboration. Papers were both qualitative and quantitative in design, and focused largely on WPL of collaborating general practitioners and nurses. No striking differences between different professionals within primary healthcare were noted. Professionals were often unaware of the learning that occurs through collaboration. WPL happened predominantly through informal discussions about patient cases and modeling for other professionals. Any professionals could both learn and facilitate others' learning. Outcomes were diverse, but contextualized knowledge seemed to be important. DISCUSSION/CONCLUSIONS: Primary care professionals' WPL is multifaceted. Existing social constructivist and social cognitivist learning theories form a framework from which to interpret these findings. Primary care policy makers and managers should ensure that professionals have access to protected time, earmarked for learning. Time is required for reflection, to learn new ways of interaction and to develop new habits within clinical practice.

Healthcare teams as complex adaptive systems: Focus on interpersonal interaction.

OBJECTIVE: The aim of this study is to test the feasibility of a tool to objectify the functioning of healthcare teams operating in the complexity zone, and to evaluate its usefulness in identifying areas for team quality improvement. METHODS: We distributed The Complex Adaptive Leadership (CAL™) Organisational Capability Questionnaire (OCQ) to all members of one palliative care team (n=15) and to palliative care physicians in Flanders, Belgium (n=15). Group discussions were held on feasibility aspects and on the low scoring topics. Data was analysed calculating descriptive statistics (sum score, mean and standard deviation). The one sample T-Test was used to detect differences within each group. RESULTS: Both groups of participants reached mean scores ranging from good to excellent. The one sample T test showed statistically significant differences between participants' sum scores within each group (p<0,001). Group discussion led to suggestions for quality improvement e.g. enhanced feedback strategies between team members. CONCLUSION: The questionnaire used in our study shows to be a feasible and useful instrument for the evaluation of the palliative care teams' day-to-day operations and to identify areas for quality improvement. PRACTICAL IMPLICATIONS: The CAL™OCQ is a promising instrument to evaluate any healthcare team functioning. A group discussion on the questionnaire scores can serve as a starting point to identify targets for quality improvement initiatives.

Peer-review for selection of oral presentations for conferences: Are we reliable?

INTRODUCTION: Although peer-review for journal submission, grant-applications and conference submissions has been called 'a counter- stone of science', and even 'the gold standard for evaluating scientific merit', publications on this topic remain scares. Research that has investigated peer-review reveals several issues and criticisms concerning bias, poor quality review, unreliability and inefficiency. The most important weakness of the peer review process is the inconsistency between reviewers leading to inadequate inter-rater reliability. AIM OF THE PAPER: To report the reliability of ratings for a large international conference and to suggest possible solutions to overcome the problem. METHODS: In 2016 during the International Conference on Communication in Healthcare, organized by EACH: International Association for Communication in Healthcare, a calibration exercise was proposed and feedback was reported back to the participants of the exercise. RESULTS: Most abstracts, as well as most peer-reviewers, receive and give scores around the median. Contrary to the general assumption that there are high and low scorers, in this group only 3 peer-reviewers could be identified with a high mean, while 7 has a low mean score. Only 2 reviewers gave only high ratings (4 and 5). Of the eight abstracts included in this exercise, only one abstract received a high mean score and one a low mean score. Nevertheless, both these abstracts received both low and high scores; all other abstracts received all possible scores. DISCUSSION: Peer-review of submissions for conferences are, in accordance with the literature, unreliable. New and creative methods will be needed to give the participants of a conference what they really deserve: a more reliable selection of the best abstracts. PRACTICE IMPLICATIONS: More raters per abstract improves the inter-rater reliability; training of reviewers could be helpful; providing feedback to reviewers can lead to less inter-rater disagreement; fostering negative peer-review (rejecting the inappropriate submissions) rather than a positive (accepting the best) could be fruitful for selecting abstracts for conferences.

How family physicians respond to unpleasant emotions of ethnic minority patients.

OBJECTIVE: The diversity in our society makes patient-centered care more difficult. In this study, we aim to describe how family physicians respond to unpleasant emotions of ethnic minority patients. METHODS: One hundred ninety one consultations of family physicians with ethnic minority patients were video-recorded and analyzed using the Verona Codes for Provider Responses (VR-CoDES-P) to describe physicians' responses to patients' expressed unpleasant emotions or cues (implicit) and concerns (explicit). RESULTS: 42.4% (n=81) of all the consultations contained no cues or concerns, and thus no physician responses. Of the consultations containing at least one cue or concern, a mean of 3.45 cues and a mean of 1.82 concerns per consultation were found. Physicians are significantly (p≤0.001) more frequently stimulating further disclosure of patients' cues and concerns (providing space: n=339/494 or 68.6% versus reducing space: n=155/494 or 31.4%). However, these explorations are more often about the factual, medical content of the cue than about the emotion itself (n=110/494 or 22.3% versus n=79/494 or 16%). The inter-physician variation in response to patients' cues is larger than the variation in response to the patient's concerns. CONCLUSIONS: Although family physicians are quite often providing room for patients' emotions, there is much room for improvement when it comes to explicitly talking about emotional issues with patients. PRACTICE IMPLICATIONS: Further research should focus on a more qualitative in-depth analysis of the complex interplay between culture and language of ethnic minority patients in primary care and, consequently, create awareness among these healthcare providers about the importance of ethnic minority patients' emotions and how to respond accordingly.

Experiences of hospital-based multidisciplinary team meetings in oncology: An interview study among participating general practitioners.

BACKGROUND: Cancer care has become complex, requiring healthcare professionals to collaborate to provide high-quality care. Multidisciplinary oncological team (MDT) meetings in the hospital have been implemented to coordinate individual cancer patients' care. General practitioners (GPs) are invited to join, but their participation is minimal. OBJECTIVES: Aim of this study is to explore participating GPs' perceptions of their current role and to understand their preferences towards effective role execution during MDT meetings. METHODS: In May to June 2014, semi-structured interviews (n = 16) were conducted involving GPs with MDT experience in Belgium. The analysis was done according to qualitative content analysis principles. RESULTS: Attendance of an MDT meeting is perceived as part of the GP's work, especially for complex patient care situations. Interprofessional collaborative relationships and the GP's perceived benefit to the MDT meeting discussions are important motivators to participate. Enhanced continuity of information flow and optimized organizational time management were practical aspects triggering the GP's intention to participate. GPs valued the communication with the patient before and after the meeting as an integral part of the MDT dynamics. CONCLUSION: GPs perceive attendance of the MDT meeting as an integral part of their job. Suggestions are made to enhance the efficiency of the meetings.

How can pharmacists develop patient-pharmacist communication skills? A realist review protocol.

BACKGROUND: Good patient-pharmacist communication improves health outcomes. There is, however, room for improving pharmacists' communication skills. These develop through complex interactions during undergraduate pharmacy education, practice-based learning and continuing professional development. Research is needed to determine how best to approach teaching patient-pharmacist communication. METHODS: The aim of the research is to understand how educational interventions develop patient-pharmacist interpersonal communication skills produce their effects. A realist review approach will be used to synthesise the literature to make sense of the complexities of educational interventions. Our review will iteratively progress through the various stages of clarifying scope, locating existing theories, searching for evidence, appraisal of papers, data extraction and synthesis. A scoping review revealed a number of substantive theories, which will be used to build an initial programme theory. This will be explored through available published evidence, which we will find by searching databases such as Medline, EMBASE, PsychInfo, ERIC, Scopus and Web of Science. Judgements will be made on the relevance and rigour of the retrieved literature and will be taken into consideration during analysis and synthesis. Synthesis, testing and refinement of the theories will describe and explain the links between contexts, mechanisms and outcomes of educational interventions for communication development in pharmacy. DISCUSSION: The realist review will provide an analysis of what works when, for whom, how and why, for educational interventions for interpersonal patient-pharmacist communication development. We will also explore barriers to successful communications training and acknowledge any limitations. Ultimately, we plan to provide pharmacy educators with evidence for how best to incorporate educational interventions for communications skills development into pharmacy curricula and for life-long learning opportunities for pharmacists.

Victims of disaster: can ethical debriefings be of help to care for their suffering?

Victims of disaster suffer, not only at the very moment of the disaster, but also years after the disaster has taken place, they are still in an emotional journey. While many moral perspectives focus on the moment of the disaster itself, a lot of work is to be done years after the disaster. How do people go through their suffering and how can we take care of them? Research on human suffering after a major catastrophe, using an ethics of care perspective, is scarce. People suffering from disasters are often called to be in distress and their emotional difficulties 'medicalised'. This brings them often into a situation of long term use of medication, and one can wonder if medication is of help to them in the long run. In our paper, we will explore another moral perspective, focusing on the importance of the victims' narrative and their lived experiences. We will use Paul Ricoeur's phenomenological reflections from 'Suffering is not the same as pain' for conceptualizing human suffering and how to apply it to victims of disaster. Ricoeur suggests that suffering is not a quantity that can be measured, but a characteristic that should be studied qualitatively in interpersonal and narrative contexts. Above all, the perspective of care and listening could offer an opportunity to reconcile people from their loss and suffering.

Dutch translation and validation of the readiness for interprofessional learning scale (RIPLS) in a primary healthcare context.

BACKGROUND: Interprofessional education and collaborative practice are gradually gaining importance in the context of growing healthcare complexity. The readiness for interprofessional learning scale (RIPLS) is a well-known scale that can identify attitudinal barriers and variance across professions, which may affect educational interventions. OBJECTIVES: This study aims to translate the English RIPLS into Dutch and to test its reliability and validity. METHODS: The scale was translated and back-translated by two pairs of people independently and tested for feasibility and comprehensibility. The translated scale was used with 219 general practitioners, 238 community nurses, and 53 palliative home-care nurses. Exploratory factor analysis was used to assess construct validity. Confirmatory factor analysis was done to generate a fit model. Cronbach's alpha was computed to evaluate internal consistency. Regression analysis was used to evaluate the effect of the RIPLS score on the level of learning through collaboration and to gauge the influence of the participants' gender, age, previous palliative care education, type of practice and years in practice. RESULTS: Confirmatory and exploratory factor analysis confirms the factor structure of the original version. The Dutch version shows good reliability (overall Cronbach's alpha: 0.88; intraclass correlation coefficient after test-retest: 0.718 (95%CI: 0.499-0.852). The RIPLS score correlates with the amount of workplace learning during collaboration (discriminant validity: P < 0.001). CONCLUSION: The Dutch translation of the RIPLS is now ready for comparative studies.