Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
BMC Palliative Care
Published in: BMC Palliative Care 1/2018

Open Access 01-12-2018 | Research article

How can end of life care excellence be normalized in hospitals? Lessons from a qualitative framework study

Authors: Christy Noble, Laurie Grealish, Andrew Teodorczuk, Brenton Shanahan, Balaji Hiremagular, Jodie Morris, Sarah Yardley

Published in: BMC Palliative Care | Issue 1/2018

Login to get access

Abstract

Background

There is a pressing need to improve end-of-life care in acute settings. This requires meeting the learning needs of all acute care healthcare professionals to develop broader clinical expertise and bring about positive change. The UK experience with the Liverpool Care of the Dying Pathway (LCP), also demonstrates a greater focus on implementation processes and daily working practices is necessary.

Methods

This qualitative study, informed by Normalisation Process Theory (NPT), investigates how a tool for end-of-life care was embedded in a large Australian teaching hospital. The study identified contextual barriers and facilitators captured in real time, as the ‘Clinical Guidelines for Dying Patients’ (CgDp) were implemented. A purposive sample of 28 acute ward (allied health 7 [including occupational therapist, pharmacists, physiotherapist, psychologist, speech pathologist], nursing 10, medical 8) and palliative care (medical 2, nursing 1) staff participated. Interviews (n = 18) and focus groups (n = 2), were audio-recorded and transcribed verbatim. Data were analysed using an a priori framework of NPT constructs; coherence, cognitive participation, collective action and reflexive monitoring.

Results

The CgDp afforded staff support, but the reality of the clinical process was invariably perceived as more complex than the guidelines suggested. The CgDp ‘made sense’ to nursing and medical staff, but, because allied health staff were not ward-based, they were not as engaged (coherence). Implementation was challenged by competing concerns in the acute setting where most patients required a different care approach (cognitive participation). The CgDp is designed to start when a patient is dying, yet staff found it difficult to diagnose dying. Staff were concerned that they lacked ready access to experts (collective action) to support this. Participants believed using CgDp improved patient care, but there was an absence of participation in real time monitoring or quality improvement activity.

Conclusions

We propose a model, which addresses the risks and barriers identified, to guide implementation of end-of-life care tools in acute settings. The model promotes interprofessional and interdisciplinary working and learning strategies to develop capabilities for embedding end of life (EOL) care excellence whilst guided by experienced palliative care teams. Further research is needed to determine if this model can be prospectively applied to positively influence EOL practices.
Literature
1.
Virdun C, et al. Dying in the hospital setting: a systematic review of quantitative studies identifying the elements of end-of-life care that patients and their families rank as being most important. Palliat Med. 2015;29(9):774–96.CrossRefPubMedPubMedCentral
2.
Gomes B, Higginson IJ. Where people die (1974—2030): past trends, future projections and implications for care. Palliat Med. 2008;22(1):33–41.CrossRefPubMed
3.
Broad JB, et al. Where do people die? An international comparison of the percentage of deaths occurring in hospital and residential aged care settings in 45 populations, using published and available statistics. Int J Public Health. 2013;58(2):257–67.CrossRefPubMed
4.
Swerissen, H. and S. Duckett, Dying Well, G. Institute, Editor. 2014, Grattan Institute: Carlton, Victoria p 37.
5.
Costantini M, Alquati S, Di Leo S. End-of-life care: pathways and evidence. Curr Opin Support Palliat Care. 2014;8(4):399–404.CrossRefPubMed
6.
Australian Commission on Safety and Quality in Health Care, National Consensus Statement: essential elements for safe and high-quality end-of-life care in acute hospitals. 2015, Australian Commission on Safety and Quality in Health Care: Sydney, NSW, Australia.
7.
Robinson J, Gott M, Ingleton C. Patient and family experiences of palliative care in hospital: what do we know? An integrative review. Palliat Med. 2014;28(1):18–33.CrossRefPubMed
8.
Department of Health, More care less pathway: a review of the Liverpool Care Pathway. 2013, Crown Copyright.
9.
10.
McConnell T, et al. Factors affecting the successful implementation and sustainability of the Liverpool care pathway for dying patients: a realist evaluation. BMJ Support Palliat Care. 2014;
11.
McConnell T, et al. Systematic realist review of key factors affecting the successful implementation and sustainability of the Liverpool care pathway for the dying patient. Worldviews Evid-Based Nurs. 2013;10(4):218–37.CrossRefPubMed
12.
Palliative Care Australia, Standards for Providing Quality Palliative Care for all Australians. 2005, Palliative Care Australia: Deakin West, ACT.
13.
Crotty M. The foundations of social research. London: SAGE Publications Ltd.; 1998.
14.
May C, Finch T. Implementing, embedding, and integrating practices: an outline of normalization process theory. Sociology. 2009;43(3):535–54.CrossRef
15.
May C, et al. Understanding the implementation of complex interventions in health care: the normalization process model. BMC Health Serv Res. 2007;7(1):148.CrossRefPubMedPubMedCentral
16.
Ritchie, J. and L. Spencer, Qualitative data analysis for applied policy research, in Analyzing Qualitative Data, A. Bryman and R. Burgess, editors. 1994, RoutledgeFalmer: London.
17.
Murray E, et al. Normalisation process theory: a framework for developing, evaluating and implementing complex interventions. BMC Med. 2010;8(1):1–11.CrossRef
18.
19.
20.
Creswell JW. Qualitative inquiry and research design: choosing among five approaches. London: SAGE Publications Ltd.; 2013.
21.
Johnson MJ, May CR. Promoting professional behaviour change in healthcare: what interventions work, and why? A theory-led overview of systematic reviews. BMJ Open. 2015;5(9):1–13.
22.
Cummings A, et al. Implementing communication and decision-making interventions directed at goals of care: a theory-led scoping review. BMJ Open. 2017;7(10):1–17.
23.
Billett S, Choy S. Learning through work: emerging perspectives and new challenges. J Work Learn. 2013;25(4):264–76.CrossRef
24.
Sleeman KE, et al. ‘It doesn't do the care for you’: a qualitative study of health care professionals' perceptions of the benefits and harms of integrated care pathways for end of life care. BMJ Open. 2015;5(9):1–7.
25.
Twigger S, Yardley SJ. Hospital doctors’ understanding of use and withdrawal of the Liverpool care pathway: a qualitative study of practice-based experiences during times of change. Palliat Med. 2017;31(9):833–41.CrossRefPubMed
26.
Di Leo S, et al. ‘Less ticking the boxes, more providing support’: a qualitative study on health professionals’ concerns towards the Liverpool Care of the Dying Pathway. Palliat Med. 2015;29(6):529–37.CrossRefPubMed
27.
White N, et al. How accurate is the ‘surprise question’ at identifying patients at the end of life? A systematic review and meta-analysis. BMC Med. 2017;15(1):139.CrossRefPubMedPubMedCentral
28.
Edwards A, Daniels H, Gallagher T, Leadbetter J, Warmington P. Improving inter-professional collaborations: Multi-agency working for children's wellbeing. Oxon: Routledge; 2009.
29.
Raijmakers N, et al. Barriers and facilitators to implementation of the Liverpool care pathway in the Netherlands: a qualitative study. BMJ Support Palliat Care. 2015;5(3):259–65.CrossRefPubMed
30.
Billett S. Learning through work: workplace affordances and individual engagement. J Work Learn. 2001;13(5/6):209–14.CrossRef
31.
Lincoln, Y. and E. Guba, Naturalistic Inquiry. 1985, Newbury Park, CA: Sage Publications.
32.
Teodorczuk A, et al. Medical education research should extend further into clinical practice. Med Educ. 2017;51(11):1098–100.CrossRefPubMed
33.
Kilbertus FMDM, Ajjawi RP, Archibald DBP. "You're Not Trying to Save Somebody From Death": Learning as "Becoming" in Palliative Care. Acad Med. 2018;93(6):929–36.
34.
Billett S. Securing intersubjectivity through interprofessional workplace learning experiences. J Interprofessional Care. 2014;28(3):206–11.CrossRef
35.
Smith D. Institutional ethnography as practice. Oxford: Rowan and Littlefield; 2006.
36.
Boud, D. and E. Molloy, Feedback in Higher and Professional Education: Understanding it and doing it well. 2013, New York: Routledge.
37.
Metadata
Title
How can end of life care excellence be normalized in hospitals? Lessons from a qualitative framework study
Authors
Christy Noble
Laurie Grealish
Andrew Teodorczuk
Brenton Shanahan
Balaji Hiremagular
Jodie Morris
Sarah Yardley
Publication date
01-12-2018
Publisher
BioMed Central
Published in
BMC Palliative Care / Issue 1/2018
Electronic ISSN: 1472-684X
DOI
https://doi.org/10.1186/s12904-018-0353-x

Other articles of this Issue 1/2018

BMC Palliative Care 1/2018 Go to the issue

Research article

The provision of generalist and specialist palliative care for patients with non-malignant respiratory disease in the North and Republic of Ireland: a qualitative study

Research article

Allow natural death versus do-not-resuscitate: titles, information contents, outcomes, and the considerations related to do-not-resuscitate decision

Research article

Analysis of factors delaying the surgical treatment of patients with neurological deficits in the course of spinal metastatic disease

Research article

The degree of social difficulties experienced by cancer patients and their spouses

Research article

Bridging gaps in everyday life – a free-listing approach to explore the variety of activities performed by physiotherapists in specialized palliative care

Research article

Factors associated with emergency services use in Taiwanese advanced cancer patients receiving palliative home care services during out-of-hours periods: a retrospective medical record study