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Implementation of knowledge-based palliative care in acute care settings: obstacles, opportunities and experiences
Karolinska institutet.
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background and aim: Quality improvement is continuously ongoing at different levels in our healthcare system. In Sweden, as in other countries, guidelines are important for quality improvement in healthcare, since they summarize the best available evidence. Improved living conditions and enhanced treatments for a variety of diseases have resulted in increased longevity and the need for palliative care has therefore also increased. A high proportion of deaths occur in acute care settings, where the care has been described as inadequate for dying patients. In 2013, the National Board of Health and Welfare published A National knowledgebased guidance for good palliative care in end-of-life care and just prior to this in 2012, the Regional Cancer Centre published the National clinical practice guideline for palliative care. The overarching aim of this thesis was to study implementation of knowledge-based palliative care in acute care settings.

Methods and results of the studies: The first and second studies covered aspects that were to be taken into account for the implementation of the documents described above. In study I, national policy documents in Sweden were reviewed for quality indicators relevant to palliative care and end-of-life care. In study II, perceptions regarding national palliative care guidelines were investigated and obstacles to and opportunities for implementing these guidelines in acute care hospitals were identified through interviews with local politicians, chief medical officers and healthcare professionals. The results showed scarce knowledge of the two documents at all levels of the healthcare organisation. Palliative care was primarily described as end-of- life care. The environment and culture in hospitals, with heavy workload, poor communication and poor teamwork, were described as obstacles for implementation. However, staff emphasised a need for training and support in palliative care through theoretical knowledge and mentoring to develop clinical skills. An implementation strategy for the use of the Integrated Palliative care Outcome Scale (IPOS) was developed. The strategy included information, training and facilitation to support the use of the scale. The implementation was performed at three acute care settings and, to gain a broader understanding of the strategy, it was also tested at a palliative care unit. The evaluation of the strategy, presented in study III and IV, was conducted through multiple methods. The findings showed varying prevalence of completed IPOS, indicating shortcomings in implementation.

Conclusion: The awareness of the two documents on palliative care varied at all levels in the healthcare organisation, being predominantly low among healthcare professionals in acute care settings. The feasibility of the performed implementation strategy was considered questionable and the components need to be further explored to enhance the impact of implementation and thereby improve the use of IPOS in acute care settings.

Place, publisher, year, edition, pages
Stockholm: Karolinska institutet , 2018. , p. 65
National Category
Nursing
Identifiers
URN: urn:nbn:se:esh:diva-7397Libris ID: 22408667ISBN: 978-91-7676-918-8 (print)OAI: oai:DiVA.org:esh-7397DiVA, id: diva2:1305316
Public defence
2018-01-24, Bringsalen, Ersta Konferens och hotel, , Stockholm, Erstagatan 1, Stockholm, 00:00 (Swedish)
Supervisors
Available from: 2019-04-16 Created: 2019-04-16 Last updated: 2019-04-16Bibliographically approved
List of papers
1. Quality indicators for palliative and end of life care: a review of Swedish policy documents
Open this publication in new window or tab >>Quality indicators for palliative and end of life care: a review of Swedish policy documents
2013 (English)In: BMJ Supportive & Palliative Care, ISSN 2045-435X, E-ISSN 2045-4368, Vol. 3, no 2, p. 174-180Article in journal (Refereed) Published
Abstract [en]

Background All patients with palliative and end of life care needs should be guaranteed equal and safe treatment and care, regardless of their disease or site of care. The inclusion of quality indicators in national guidelines and other guiding documents supports quality assurance and improvement in provision of care. The aim of this paper was to review existing quality indicators in national Swedish policy documents relevant to palliative and end of life care.

Methods We reviewed existing guidelines for diseases expected to require palliative care issued by the National Board of Health and Welfare, existing regional clinical practice guidelines and the annual report of the Swedish Register of Palliative Care (SRPC) up until 2010.

Results We found 11 quality indicators pertinent to palliative and end of life care in the guidelines for cancer diseases and ‘The care and nursing of the elderly’. The indicators included assessment and treatment of pain, communication with the patient and the family, documentation in the patient record and registration in the SRPC. In the national guidelines for cardiology, pulmonary diseases, stroke, diabetes and dementia, there were no indicators relevant for palliative or end of life care.

Conclusions In the existing Swedish national guidelines for many different diseases, there is still a great need to define clinically relevant and feasible outcome measures of quality of palliative and end of life care.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:esh:diva-2531 (URN)10.1136/bmjspcare-2012-000390 (DOI)
Available from: 2013-12-03 Created: 2013-12-03 Last updated: 2019-04-16Bibliographically approved
2. Implementation of national palliative care guidelines in Swedish acute care hospitals: A qualitative content analysis of stakeholders' perceptions.
Open this publication in new window or tab >>Implementation of national palliative care guidelines in Swedish acute care hospitals: A qualitative content analysis of stakeholders' perceptions.
Show others...
2017 (English)In: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, Vol. 121, no 11, p. 1194-1201, article id S0168-8510(17)30239-7Article in journal (Refereed) Published
Abstract [en]

In high-income countries a large proportion of all deaths occur in hospitals. A common way to translate knowledge into clinical practice is developing guidelines for different levels of health care organisations. During 2012, national clinical guidelines for palliative care were published in Sweden. Later, guidance for palliative care was issued by the National Board of Health and Welfare. The aim of this study was two-fold: to investigate perceptions regarding these guidelines and identify obstacles and opportunities for implementation of them in acute care hospitals. Interviews were conducted with local politicians, chief medical officers and health professionals at acute care hospitals. The Consolidated Framework for Implementation Research was used in a directed content analysis approach. The results showed little knowledge of the two documents at all levels of the health care organisation. Palliative care was primarily described as end of life care and only few of the participants talked about the opportunity to integrate palliative care early in a disease trajectory. The environment and culture at hospitals, characterised by quick decisions and actions, were perceived as obstacles to implementation. Health professionals' expressed need for palliative care training is an opportunity for implementation of clinical guidelines. There is a need for further implementation of palliative care in hospitals. One option for further research is to evaluate implementation strategies tailored to acute care.

Keywords
Acute care hospital, Consolidated framework for implementation research, Guidelines, Implementation, Palliative care
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:esh:diva-6643 (URN)10.1016/j.healthpol.2017.09.011 (DOI)28969921 (PubMedID)
Available from: 2018-02-15 Created: 2018-02-15 Last updated: 2019-04-16Bibliographically approved
3. Implementation of the integrated palliative care outcome scale in acute care settings: a feasibility study.
Open this publication in new window or tab >>Implementation of the integrated palliative care outcome scale in acute care settings: a feasibility study.
Show others...
2018 (English)In: Palliative & Supportive Care, ISSN 1478-9515, E-ISSN 1478-9523, Vol. 16, no 6, p. 698-705Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: Although hospitals have been described as inadequate place for end-of-life care, many deaths still occur in hospital settings. Although patient-reported outcome measures have shown positive effects for patients in need of palliative care, little is known about how to implement them. We aimed to explore the feasibility of a pilot version of an implementation strategy for the Integrated Palliative care Outcome Scale (IPOS) in acute care settings.

METHOD: A strategy, including information, training, and facilitation to support the use of IPOS, was developed and carried out at three acute care units. For an even broader understanding of the strategy, it was also tested at a palliative care unit. A process evaluation was conducted including collecting quantitative data and performing interviews with healthcare professionals. Result Factors related to the design and performance of the strategy and the context contributed to the results. The prevalence of completed IPOS in the patient's records varied from 6% to 44% in the acute care settings. At the palliative care unit, the prevalence in the inpatient unit was 53% and the specialized home care team 35%. The qualitative results showed opposing perspectives concerning the training provided: Related to everyday work at the acute care units and Nothing in it for us at the palliative care unit. In the acute care settings, A need for an improved culture regarding palliative care was identified. A context characterized by A constantly increasing workload, a feeling of Constantly on-going changes, and a feeling of Change fatigue were found at all units. Furthermore, the internal facilitators and the nurse managers' involvement in the implementation differed between the units. Significance of the results The feasibility of the strategy in our study is considered to be questionable and the components need to be further explored to enhance the impact of the strategy and thereby improve the use of IPOS.

Keywords
Implementation, Acute care settings, Facilitation, Integrated palliative care outcome scale, Palliative care
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:esh:diva-6633 (URN)10.1017/S1478951517001158 (DOI)29352836 (PubMedID)
Available from: 2018-02-15 Created: 2018-02-15 Last updated: 2019-04-16Bibliographically approved
4. The integrated palliative care outcome scale for patients with palliative care needs: Factors related to and experiences of the use in acute care settings.
Open this publication in new window or tab >>The integrated palliative care outcome scale for patients with palliative care needs: Factors related to and experiences of the use in acute care settings.
2019 (English)In: Palliative & Supportive Care, ISSN 1478-9515, E-ISSN 1478-9523, p. 1-8Article in journal (Refereed) Epub ahead of print
Abstract [en]

OBJECTIVE: Implementation of patient-reported outcome measures for patients with palliative care needs is characterized by both enablers and barriers. The ways in which healthcare professionals experience the use of assessment tools is important. Our aims were to explore factors contributing to or hindering patients with palliative care needs in assessing their symptoms with the Integrated Palliative Care Outcome Scale (IPOS) and to explore healthcare professionals' experiences of the use of IPOS in acute care settings.

METHOD: Data were collected as a part of the evaluation of the feasibility of an implementation strategy for introducing IPOS. Data from three participating acute care units were included. We used descriptive and analytical statistics; a qualitative content analysis was also performed.ResultA total of 309 patients were eligible to be offered assessment of symptoms with IPOS. Of these 69 (22%) had completed IPOS. A significant positive association was found between healthcare professionals' participation in training sessions and completed IPOS. The experiences of IPOS were split into two categories: "IPOS acting as a facilitator" and "barriers to the use of IPOS." The use of IPOS was described as contributing to person-centered care of patients with palliative care needs and inspiration to improved routines. Healthcare professionals' feelings of uncertainty about how to approach severely ill patients and their family members appear to have hindered their use of IPOS.Significance of resultsWe found an association between healthcare professionals' participation in training sessions and patients who completed IPOS, indicating the need for a high degree of attendance at the training to achieve successful implementation. The healthcare professionals expressed feelings of insecurity concerning the use of IPOS indicating a need for further education and clinical support in its use of IPOS. Nevertheless, use of IPOS was considered to contribute to improved care of patients with palliative care needs.

Keywords
Acute care settings, Implementation, Integrated palliative care, Mixed-method, Outcome scale, Palliative care
National Category
Nursing
Identifiers
urn:nbn:se:esh:diva-7396 (URN)10.1017/S1478951518001104 (DOI)30841947 (PubMedID)
Available from: 2019-04-16 Created: 2019-04-16 Last updated: 2019-04-16Bibliographically approved

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