Sharing Current Scottish Practice

Inspiring Leadership leading self; leading with others in a palliative care setting

Author(s)

Claire O’Neill, Jane Miller, Susan Jackson, Fiona Wylie.

Aims:

Pilot and evaluate a leadership programme for band 6 Palliative Care Clinical Nurse Specialist’s working within NHSGGC acute and hospices. The programme focussed on the leadership behaviours set out in the NHS Scotland Leadership Qualities Framework.

Methodology:

The programme aims included to build participants personal effectiveness, resilience and create a network of support, develop leadership behaviours consistent with an enabling culture and deliver a quality improvement project demonstrating impact on patient and families’ care experience. Participants attended master classes on:

• Myers Briggs and Working with Differences

• Quality Improvement Methodology

• Influencing skills

• Strategic landscape for Palliative Care.

They undertook 360 review with feedback sessions linking with PDPs, Action Learning Sets, shadowing opportunities and completed a work-based QI project.

The programme was evaluated using a combination of quantitative and qualitative data collection methods.

Results:

The evaluation data indicates that this was a very effective programme. The line manager / key person qualitative data supported the views of the participants by giving tangible examples of the impact of the programme at individual, patient, team and organisational levels.

Recommendations:

The outstandingly positive evaluation of the programme supports the view there is a need for this programme to continue.

Investigating the need for palliative care among people who are homeless in Scotland

Author(s)

Joy Rafferty

A scoping exercise assessed the need for palliative care among people who are homeless in Scotland. Published homelessness data estimated the number of homeless people in Scotland. Literature review examined morbidity and mortality, challenges of providing palliative care to homeless people and their views on palliative care.
There were 34,100 homelessness applications in Scotland in 2016/17 though the true number of homeless people is likely double this. The literature shows complex palliative care needs with homeless people having significantly worse symptoms at end of life than other populations. Challenges to providing palliative care described in the literature include uncertain prognostication, complex trauma, chaotic lifestyles, service design and delivery and few available options. In published research homeless people expressed fears of dying anonymously, alone, on the streets and not being found and of being forgotten after death. Self-determination was vital, with concerns admission would cause a loss of freedom and control. Psychosocial care, staff availability, continuity and developing trusting relationships were essential. The importance of staff reaching out was expressed.
We need to consider how palliative care services can be more accessible and responsive to the needs of people who are homeless in Scotland.

Kilbryde Hospice to Kirriemuir Nursery: See how our garden grows!

Author(s)

Karen Kilpatrick; Melissa Woodhouse

Background:
Kilbryde Hospice Day Services, providing a rehabilitative model of care, was keen to introduce therapeutic horticulture to promote independence and promote wellbeing. Equally, a local nursery wished to establish a link to the hospice. A joint project to promote an intergenerational partnership was established in April 2018 to establish and maintain the external gardens in the new hospice grounds. Epstein & Boisvert (2006) reported the benefits of an intergenerational space that is shared whilst Kaplan, (1995) acknowledges the use of natural environments to be beneficial in promoting wellbeing. This project endorses Scottish Government Health& Social Care Standards (2017) to encourage hospice staff to provide activities that patients can participate in either indoors or outdoors.
Aim:
To provide social and therapeutic horticulture to Kilbryde Hospice Day Services patients improving their wellbeing through active or passive gardening. Involving the nursery children allows a working relationship to develop, expanding their knowledge of plant life and develop their social skills within the hospice environment.
Method:
Nursery:
• Weekly visits by nursery children to hospice for 30 minutes
• No more than 8 children in a group at the one time
• Children accompanied by 2 or 3 staff members
• Kirriemuir staff fully responsible for the children on their visit
• Hi-visibility vests provided by nursery to be worn by children
• Children and patients to maintain 3 main garden areas; patio, front garden and rear garden.
Hospice:
• Therapeutic horticulture planned within Hospice Day Services 13-week programme
• Provision of one clinical support worker and 2 volunteers per session
• Patient choice to attend the session
• All levels of mobility catered for
• Fundraising Team at Kilbryde arranged for donation of plants and soil.
Results:
6 patients with regular horticulture participation
• IPOS scores decreased in feelings of anxiety and worry in 3 patients
• IPOS scores improved in feeling depressed in 3 patients
Children:
“I like going to help everyone at the hospice” HL
“I loved all the plants because some were coloured” JD
Kilbryde Patients:
“Kids make us laugh with what they say and do” AMH
“Both patients and children enjoy mixing. Long may it continue!” TH
Nursery Staff:
“Promotes the bond between adults and children working together” MW
“Children have developed a sense of responsibility” JA
Kilbryde Volunteers:
“Loved listening to kids asking patients about plants” ME
“Watching the children interested in the flowers and sharing tasks, they brightened up the patient’s day.” MI
Conclusion:
• Improved outcomes on measuring feelings of anxiety, worry, depression
• Apparent improvement in social isolation
• Introduction of therapeutic horticulture has now been embedded into Day Services 13-week
programme.
• A planned seasonal project has extended to throughout the year with periodic adjustments
• Exclusively positive feedback from all 4 sources
• Nursery visits have increased to twice a week as a result.
References:
Epstein,A.S. & Boisvert,C. (2006) Let's Do Something Together Journal of Intergenerational Relationships. 4 3 87-109
Kaplan S. (1995) The restorative benefits of nature: Toward an integrative framework. Journal of Environmental Psychology. 15(3):169-182.
Scottish Government (2017) Health & Social care Standards. My support, my life. Crown Copyright

Lessons learned from integration of IPOS into the Community: Building relationships and sharing learning and understanding between Specialist and Generalist Palliative Care Services

Author(s)

Neill Cree; Dr G Dunnet; Dr S McConnell; Dr J McKane; Janice Renfrew; Dr C Sime; Dr John Thompson; Dr Margaret Thompson

The aim of the project was to embed the use of the Integrated Palliative Outcome Scale (IPOS) within the Inverclyde Community Primary Care teams. IPOS is a validated and reliable tool used to identify unmet needs for people living with a life limiting illness. IPOS use within primary care is an innovative strategy. IPOS use in Specialist Palliative Care Services is well established.
We identified key barriers and challenges to collaborative inter-disciplinary working within Generalist and Specialist services. We acknowledged the different priorities in managing patients with life limiting illnesses and focused on innovative solutions to translate and integrate the use of IPOS into the Community.
We had to establish project momentum by supporting community staff. We developed case-based reflections, education and mentorship programmes to enable practices to embed IPOS development whilst supporting teams to develop clinical governance solutions to allow maximal impact of IPOS. We trained IPOS champions in the community to allow learning to be shared.
We identified key barriers and developed multifaceted solutions for the interaction and communication between Generalist and Specialist Palliative Care Services during integration of a new tool in an environment where Generalists have competing demands, specific to their specialty.

Lifetime in Pebbles

Author(s)

Shona Crain; Mairi-Ann Higgins; Ishbel Murdoch

The poster displays a creative project that tells the story of the growth of the Accord Hospice in Paisley where a large pebble mosaic has been hand painted by patients, families, volunteers, staff and local school children. The creation of the mosaic has involved the therapeutic benefits of art and is a reflection of the community the hospice is embedded in. It is installed in the gardens of the Accord Hospice.

Making a Difference – The Provision of Palliative and End of Life Care within a Community Hospital

Author(s)

Lynne Hoffin; Linda Kerr; James Mack; Dr Jillian Nicoll; Dr Kathleen Sherry; Morag Thomson; Karen Wilson

Patients in their last year of life use 30% of all acute hospital bed days. Evidence shows that over 50% of Scotland’s annual deaths take place in hospital. About 50% of NHS complaints relate to end of life care.

Community hospitals such as the Biggart Hospital play an important role in the provision of healthcare. They are at the forefront of shifting the balance of care from acute services into the community and they are ideally placed to develop a range of services focussing on the provision of palliative and end of life care.

MacMillan ward is a 23 bedded which specialises in palliative, end of life and Hospital Based Complex Continuing Care for patients with the need for frequent, sometimes not easily predictable, clinical interventions.

During a planned Leadership Walk round it was identified that there appeared to be issues with patients’ treatment being deemed unnecessarily escalated who were approaching the end of their life. Other factors identified during the transfer process were the lack of treatment plans, recognition or assessment of the palliative identity or needs of these individuals. These complexities and lack of recognition of palliative care needs were having an impact on establishing and implementing an individual’s wishes in regard to their plan of care.

This project focused on enhancing the experience for patients and their families with generalist palliative care, death, dying and bereavement needs, through the provision of specialist palliative care support/education for nursing and medical staff within MacMillan Ward.

Building on the Best – Improving palliative and end of life care in acute hospitals in Scotland

Author(s)

Kirsty Boyd; Deans Buchanan; David Gray; Trisha Hatt; Mark Hazelwood; Barbara Kimbell

The Need for Action

At any point nearly 1 in 3 hospital beds in Scotland is occupied by someone who will die within 12 months. There is a need to refine processes and to support staff to deal with this large and often complex area of work. There is also a need to prepare and support people and their families to cope with the hospital experience.

What We Did

As part of a UK-wide programme funded by Macmillan a project manager was employed by SPPC. She worked with ward staff in 3 Scottish acute hospitals with the aim of scoping practice and supporting identification and testing of improvements. The project manager also sought input from people, relatives and public. The work was guided by local palliative medicine leads but led by staff of other specialities.

Results

The commitment of general acute staff was strong, but the pressured environment meant work was slow. To varying extents wards identified and tested changes in process and/or practice. A suite of resources to prompt and support staff/individual conversations was developed and tested. Some ward processes were significantly changed in order to improve communication within the staff team.

Catastrophic Bleed Box - a practical resource within an acute setting?

Author(s)

Heather Tonner

Background:

Terminal haemorrhage (bleeding from a major blood vessel), although uncommon, causes significant distress for all involved when this catastrophic event occurs. The literature highlights the importance of good nursing care to lessen this distress. Harris et al (2011) suggest the management of terminal haemorrhage should focus on non-pharmacological, simple approaches.

Aim:

In response to traumatic events associated with catastrophic bleeding in an acute medical ward a catastrophic bleed box was developed for use across a District General Hospital.

Method:

• To facilitate discussion with ward teams regarding the care of patients at risk of terminal haemorrhage
• Identify patients at risk
• Enable sourcing of a catastrophic bleed box, including dark towels
• Provide support for staff involved in this distressing situation.

Results:

Feedback from staff that have used this resource has been sought as means of evaluation. The feedback has been extremely positive. Staff like a tangible way of preparing for a catastrophic terminal bleed. Qualitative comments imply that staff feel more confident having dark towels to hand to camouflage the blood and concentrate on calmly supporting the patient and family.

Collaborative working between renal and palliative care: The impact of an integrated service on symptom burden, advanced care planning and place of death for patients with advanced chronic kidney disease managed without dialysis.

Author(s)

Sarah Cathcart; Claire A Douglas; Lorna Frame; Maureen Lafferty; Joanne Sloan; Louisa Stage; Miles Witham

Background:

For elderly patients with comorbidity and chronic kidney disease (CKD), dialysis results in significant time spent in hospital and may not offer improved survival, compared to those managed without dialysis.

Renal and Palliative Medicine professionals developed an integrated Renal Supportive Care (RSC) service for patients with chronic kidney disease (CKD) managed without dialysis. The focus is care of CKD, symptom management and Advanced Care Planning (ACP).

The impact on symptoms and care pathways was evaluated over a 30-month period. Data collected included RSC input, Palliative Care Outcome Score (POS), ACP information and mortality data.

Results:

Those patients with RSC input had improved symptom burden. They were more likely to have improved documentation and electronic communication of ACP conversations than those without RSC input. This included Preferred Place of Care (PPC) and DNA CPR information. At end of life, those patients who had PPC documentation were significantly more likely to die in the community. Those without, were more likely to die within an acute hospital.

Conclusions:

The integrated Renal Supportive Care team achieved symptom management and Advanced Care Planning for many patients with CKD managed without dialysis and may help avoid acute hospital admissions at end of life.

Drug therapy for delirium in terminally ill adults: A Cochrane review

Author(s)

Bridget Candy; Anne Finucane; Louise Jones, Baptiste Leurent, Elizabeth Sampson; Paddy Stone; Adrian Tookman

Introduction:

Delirium is a complex neuropsychiatric syndrome common in palliative care, occurring in up to 88% of patients in the weeks or hours preceding death. Our Cochrane review on drug therapy for delirium in 2012 identified one trial (Candy et al. 2012). New trials have been conducted and an updated review is now recognised as a Cochrane priority.

Aim:

To evaluate the evidence from randomised controlled trials (RCTs) examining the effectiveness and safety of drug therapies to treat delirium in adults with a terminal illness.

Methods:

We searched for RCTs comparing any drug treatment with any other treatment for delirium in terminally ill adults.

Results:

We retrieved 9,431 citations. Four studies were included in the final review. All trials were vulnerable to bias, most commonly due to small sample size or incomplete outcome data.

Conclusion:

This review identified four trials. It found low quality evidence examining the impact of drug therapy on delirium symptoms and adverse events in terminally ill adults. Results for each comparison were based on single studies. Undertaking trials on delirium in this patient group is methodologically complex. Only one study compared drug therapy with placebo. This limited our ability to answer our review questions

End of Life Care is not Black and White

Author(s)

Rosemary Cairns; Jacqueline S Nicol; Laura Thomson

This poster illustrates the implementation of a Macmillan palliative care education resource in the acute setting. Originally developed for care home staff, this was adapted and tested in an acute setting within NHS Lothian.

The resource, Foundations in Palliative Care, comprises four modules: introduction to palliative care, communication, symptom management and bereavement. Education was delivered by the Education Lead for End of Life Care and a Senior Clinical Nurse Specialist, Hospital Palliative Care Team, four days delivered within two weeks. This was supported by Senior Management and Charge Nurses which enabled ten registrants to commit and attend all four modules.

Evaluation was extremely positive. Follow up visits from the course facilitators found participants had bridged the theory/ practice gap.

Enhanced Palliative Care for Generalists (EPCG)

Author(s)

Paul Baughan; Neil Pryde

Following feedback on the Scottish Palliative Care Guidelines, where there were comments that broader and more detailed guidance would be helpful, a proposal was taken to Macmillan to support the development of a training course for generalists.

The EPCG course will be an educational program based on the well-established model of a comprehensive, evidenced, manual underpinning a two-day interactive course.

We are preparing a pre-course manual, and an interactive 2-day course. This will include lectures, small group workshops, skill stations, and “real life” scenarios. There will be an assessment at the end.

The course will adhere to the principals of the NES framework for Palliative and End of Life Care and follow the general structure and the drug regimes of the Scottish Palliative Care Guidelines. The project has support from HIS, NES, and the SPPC.

A steering group has been established that will oversee the direction and co-ordination of the project. Class Professional Publishing will provide support and guidance throughout the project. Writing of the manual will be divided into seventeen sections. There will be a separate group to develop the interactive course. Finally, the materials will be peer reviewed, and the course piloted, prior to release.

The Inside Out Hospice Approach

Author(s)

Joyce Sweeney

The WoW Consultation

Author(s)

Dr Sheonad Laidlaw; Dr Emma Carduff

Computers are now common place in general practice. Studies have been conducted looking at the relationship and interaction between doctor, patient and computer, and show that the doctor-patient relationship changes as each relates to the computer.

Marie Curie is in the final stages of implementing an Electronic Patient Records (EPR) and Patient Administration System (PAS), via EmisWeb, enabling the recording of real time patient data on the ward by means of Workstations on Wheels (WoWs).

A qualitative study was conducted at the Glasgow hospice using a questionnaire exploring the staff’s feelings about using the WoW in a consultation; their perception of how the patient and their family would feel; how they think that the computer will affect the consultation; and the positives and negatives of using a computer with their patients.

Results show that staff are hesitant and nervous of using WoWs by the bedside, seeing it as a physical barrier to verbal and non-verbal communication, potentially impeding the rapport – and ultimately the relationship between HCP and patient. Staff see the benefit of using computers to capture patient centred data but not at the expense of their relationship with the patient.

Using poetry to describe the essence of person-centred engagement in palliative care

Author(s)

Dr Erna Haraldsdottir

Background: A small fund from Good Life, Good Death, Good Grief for a To Absent Friend activity allowed a hospice to run a poetry workshop for staff exploring the essence of engaging with dying patients in a person-centred way.

Aim: To provide a forum for staff whereby using the medium of art allowed for expressing, in a different way, person centred care engagement in the palliative care context.

Method: A poet facilitated 2-hour workshop for five members of staff in a hospice which included sharing of stories of person centred engagement with patients. Objects were used to reflect the essence of the engagement in each story and poetry written that further reflected the essence of the engagement.

Results: Seven poems were written which will be presented in the poster and all describing the uniqueness of person-centred engagement.

Evaluation: Evaluation was very positive with staff finding the workshop empowering, insightful and the creative expression therapeutic.

Using the Gold Standard Framework "trigger questions" to improve medical inpatient anticipatory care planning

Author(s)

Louise McKenna; Gillian Mulholland; Lise Axford

The Gold Standards Framework (GSF) Centre in End of Life Care “trigger questions” are used by GPs to identify patients approaching the end of life (when death is foreseeable within 12 months). Our aim was to assess if the GSF “trigger questions”, which identify general and/or clinical indicators of decline, could be used in the inpatient medical setting.

A retrospective review of electronic case notes using GSF “trigger questions” was performed using cardiac arrest call data (a proxy measure of the dying patient) from four general medical wards in Hairmyres Hospital, Lanarkshire. Between August-December 2016, 18 patients having peri-arrest/cardiac arrest events had general and/or clinical indicators of decline, indicating approaching end of life. Eight patients survived and had anticipatory care plans placed; 7 subsequently died. A second retrospective analysis was performed between February-May 2017, during which there were 5 peri-arrest/cardiac arrest events. Of these, 3 patients had GSF indicators of decline; 2 patients then had anticipatory care planning, prior to their death.

This project identifies the need to improve the recognisation of the medical inpatient approaching the end of life amongst inpatient clinicians. It suggests the use of community GSF “trigger questions” may help improve inpatient anticipatory care planning.

Working together to enable person-centred palliative and end of life care

Author(s)

Janice Logan; Dr Erna Haraldsdottir; Dr Annabel Howell; Gerry Finnan; Dr Pam Levack

Background: Education initiative that enables registered nurses from general health care settings to explore, reflect and build on their experience of palliative and end of life care practice. Classroom teaching and shadowing members of specialist palliative care team at a hospice and palliative care unit are included.

Method: Underpinning principle is the integration of experience with theory through reflection on practice and embedding of new learning into practice. Small cohort of nurses (8) undertake 3 x classroom teaching days and 2 x days clinical shadowing. Utilising the belief from adult education theory that reflection can turn experience into learning, 6 x follow up days, over 6-month period, enable the participants to construct and organise new knowledge and understanding.

Findings: One cohort is progressing with follow-up days. It is evident that the rewards of learning in this way include the depth of insight generated with associated energy and motivation contributing to new ways of working and practice improvement. Evaluation has been positive with participants finding the course engaging/inspiring, ‘discussion very helpful key, learning points identified around symptom control, ‘benefit of shadowing experience included observing a palliative specialist communicate effectively with a terminally ill patient’.

Next steps: A second cohort will commence in September.