Background
Research has demonstrated that palliative care is beneficial to both patients and families. However, it is not systematically utilized in many cases (Aslakson et al., 2014). Palliative care refers to a multidisciplinary medical care giving approach aimed at optimizing the quality of life and mitigating suffering among people with complex serious illnesses as well as their families (Al-Mahrezi& Al-Mandhari, 2016). An estimated 80 million people in the population are in need of palliative care each year. An estimated 15% of the people who need palliative care all over the world actually receive it (World Health Organization, 2018). As a result of an aging population and a rising incidence of chronic diseases, the research shows that the global need for palliative care will continue to grow (WHO, 2018).
In the United States, there are about 1.5 million people living in long term care facilities (Centers for Disease Control, 2015). Many of those patients have chronic illnesses and would benefit from palliative care services. However, there are several barriers that prevent patients from receiving palliative care in long term care facilities. Reimbursement and lack of nursing education seem to be the two major barriers why palliative care is inadequate in long term care facilities. According to Mor and Teno (2016), integrating palliative care services in long term care is behind due to the lack of support from government agencies in terms of reimbursement. This has led to the underutilization of palliative care, which has in turn led to profound negative outcomes to patients and their families as well as the health care institutions where the care is being provided.
Scope of the Problem
According to the WHO (2018), palliative care is an ethical responsibility of health systems and its integration into the mainstream public health system is essential to improving patient and system outcomes. In many acute care centers, the increasing demand to reduce the length of stay has seen many patients with chronic illness and end-stage conditions being discharged, mostly without a follow-up plan to provide them with palliative care. Additionally, many of the patients with advanced diseases are transferred to long term care facilities without proper management of their symptoms. This has usually given rise to high readmission rates, which have negative consequences for the facility and patients (Tan, 2019). In 2005, 133 million Americans were diagnosed with at least one chronic illness, and 25% of those had decreased abilities to perform their activities of daily living (Hughs & Smith, 2014). It is necessary that all long term care facilities have structures and systems in place to ensure that every patient receives the palliative care when needed (WHO, 2018). Despite these recommendations, many long term care centers and hospitals do not have a mechanism for ensuring that every patient who is eligible for palliative care actually receives it (Al-Mahrezi& Al-Mandhari, 2016). As such, patients and their families continue to suffer in the health care facility and at home.
Several tools, guidelines and policies have been developed to help nurses identify patients who may require palliative care. WHO recommends that hospitals, including long term care facilities develop palliative care programs. Unfortunately, these strategies are not consistently and systematically used in most long term care centers. The recommendation by the WHO that hospitals and long term care centers develop palliative care programs to implement the policies and guidelines has not be adopted by all facilities. An assessment by (Dumanovsky et al., 2016) showed that only 67% of hospitals in the US with at least 50 facility beds reported a palliative care program. These hospitals did not include rehabilitation centres, mental health hospitals, subacute and chronic care facilities, as well as eye, ear, nose, and throat hospitals. A total of 981 facilities were surveyed.
According to Cimino et al. (2016), palliative care has for a long time been viewed as a nursing task. Consequently, a number of healthcare professionals are not formally educated in providing palliative care or end-of-life care to patients with terminal illnesses in long term care or assisted living facilities. The lack of training and awareness of palliative care is a major barrier to enhancing access and use (WHO, 2018). Research has shown that in long term care facilities, many nurses and staff lack the skills to assessing and identify triggers for palliative care (Tan, 2019). As a result, patients and families continue to suffer, posing a great burden to the entire health system.
Health care providers need to be certain that the health services rendered to patients will be covered by health insurance. The lack of support from insurance bodies in the form of reimbursement for palliative care is a widespread problem all over the work, which has discouraged the provision of sedative care. For instance, in a study conducted by Mosoiu et al. (2018) in Romania, changes in the legislature to include funding machinery for the reimbursement of palliative care resulted in a significant increase in the number of palliative care services. In a different study conducted by Perumalswami et al. (2019), the authors report that cancer patients enrolled in hospice may fail to access certain treatment modalities that could be administered with palliative intent. This problem is attributed to the existing Medicare reimbursement plan that unnaturally divides a range of disease management processes into three indiscriminate phases of care (A, B, and D) for restorative treatment and Medicare Hospice Benefit for hospice care. This reimbursement modality affects patients’ access to care, particularly when treatment modalities cover both phases of care.
Consequences
The World Health Association recommends palliative care for patients with chronic illnesses. However, the implementation of this recommendation is low in long term care facilities. Palliative care increases comfort and quality of life in patients who no longer wish to continue receiving aggressive treatments or interventions. In patients with advanced chronic illness, failure to receive palliative care may cause more suffering (Taylor et al., 2020), constant readmissions to the hospital (Hart et al., 2018), and moving in and out of different hospitals.
Knowledge Gap
Based on the background provided above, the aim of the project is to enhance the skills of nurses working in long terms care nurses in identifying and referring patients for palliative care. There is no official tool used for determining a patient who may need palliative care in long term care facilities. This is a useful project because it will provide an evidence basis that will inform nursing practice in terms of how care is provided to long term patients.
Proposed Solution
It is important to come up with interventions to enhance the use of palliative care in health facilities as well as long term care centers. According to O’Reilly et al., (2015), evidence has demonstrated using a standardized tool increases the accuracy of palliative care assessments. A possible solution is to implement a quality improvement project targeting to increase the nurses’ knowledge in identifying and referring patients for palliative care. There is need to investigate how the implementation of a palliative care assessment tool will knowledge and referrals made by the nurses. This study intends to implement an intervention that targets at improving nurses’ knowledge about palliative care needs of the patients they take care of, as well as making referrals for palliative care. The study will provide the scientific evidence needed to inform nursing practice in terms of providing care for long term care patients.
Goals and Outcomes
The first goal of the project will be to review the literature to develop an evidence-based tool that guides the assessment of patients for palliative care. The expected outcome of this goal is to come up with a reliable, evidence-based assessment tool to help nurses to conduct accurate assessments of patients requiring palliative care. The second goal will be to speak to staff members at the hospice about the palliative care needs of patients. The anticipated outcome of this goal is to increase staff knowledge of patients’ palliative needs. Ultimately, staff members will be able to evaluate patients and offer palliative care as needed, which will improve their quality of life, enhance their satisfaction with the health care facility, and improve their overall wellbeing.
A Description of Program Structure
The quality improvement project is expected to be implemented at Victoria Nursing and Rehabilitation Center. This center has several floors each occupied by different patients. The focus will be on 50 residents on the 4th floor. Facts from the literature will be compiled to develop an evidence-based tool to direct patient assessment for palliative care. The tool will be used as a basis for staff training during brief education sessions.
The information in the tool will be summarized in PowerPoint slides to be presented to the staff members. Given that staff members are tasked with providing patient care at the hospice, the education sessions will be shortened to save time. Staff members will be allowed to ask for clarifications after the presentation and provide feedback. The total time for presentation and feedback will be expected to take 30 minutes. The information will also be printed on brochures that can be used for reference as the need arises. Therefore, the major cost of the intervention will only be attributed to brochure printing costs. The effectiveness of the intervention will be determined by gauging the levels of staff knowledge of patient assessment for palliative care before and after the brief education sessions through structured questionnaires. Statistical evaluation of staff knowledge before and after the intervention will be done using a paired t-test at 0.05 level of significance.
SWOT Analysis
Strengths
Health care systems such as Victoria Nursing and Rehabilitation Center are expected to integrate palliative care into their health systems to improve patient outcomes. Palliative care provides patients with palatable options for pain alleviation and symptom management while pursuing remedial measures (Goldonowicz et al., 2018). As a result, patients enjoy a higher quality of life. The mission of the hospice is to ensure the wellbeing and comfort of its patients at all times, which is expected to be a strength with regard to the practice problem. Staff members together with the hospice administration will be willing to embrace evidence-based solutions that improve the wellbeing of their patients.
Weaknesses
The main weakness is that staff members have inadequate knowledge and skills about patient assessment for palliative care needs. Therefore, patient referrals for palliative care are not done on time. This problem is further augmented by the lack of time for education. This weakness may pose a challenge for the project. However, the researcher anticipates taking advantage of the facility’s commitment to its mission to create time for the intervention. Another setback is the current repayment situation that hinders provider reimbursement for palliative care.
Opportunities
The WHO (2018) recommends that palliative care be provided to patients who need it as part of routine care. Nurses play a significant role in the provision of bedside care to patients and are best equipped to enhance the use of palliative care (Chover-Sierra et al., 2017). Several options can be explored in the provision of palliative care, including effective communication of patient needs, recommendations on pain management, and mitigation of disease symptoms. (Smets et al. 2018).
Threats
Currently, there are no palliative programs in place at Victoria Nursing and rehabilitation center. Patient referrals are made to the hospice very late, which delays the initiation of the much-needed palliative care. Furthermore, the poor reimbursement mechanisms complicate the provision of palliative care to patients requiring it. Consequently, the hospice tries to get patients on skilled nursing because it is reimbursed at a higher rate.
Conceptual Underpinning and Theoretical Framework
The theoretical framework that guides the project is the Theory of Human Caring, which was put forth by Jean Watson in 2008. Watson’s viewpoint of caring focuses on how nurses convey care to their patients. The basis of this theory is humanistic aspects and their association with scientific knowledge and nursing practice. Overall, nursing aims at supporting health, precluding disease, tending to the sick, and reinstating health. Watson asserts that caring is important in nursing practice and can promote better health compared to medical care that is given without care (Alharbi & Baker, 2020). Watson describes 10 carative factors that are central to nursing. They include the development of humanistic-altruistic value structures, imparting faith and hope, building a trusting relationship, inculcating compassion to self and others, encouraging the communication of feelings, creating a supportive environment, encouraging teaching and learning, and permitting existential-phenomenological forces (Pajnkihar et al., 2017). Other factors include facilitating the fulfillment of human needs and applying problem-solving skills when making decisions.
By empowering nurses to provide timely palliative care, nurses demonstrate their sensitivity to patients’ needs and show that they care. Palliative care also provides a supportive environment to promote healing and restoration. Given that palliative care assuages patients’ symptoms such as pain, it contributes to the gratification of human needs that are relevant to the patient during their hospital stay. It also instills hope for better things to come, for example, physical healing.
References
Alharbi, M. K. N., & Baker, D. O. G. (2020). Jean Watson’s middle range theory of human caring: A critique. International Journal of Advanced Multidisciplinary Scientific Research (IJAMSR) ISSN: 2581-4281, 3 (1), 1-14.
Al-Mahrezi, A., & Al-Mandhari, Z. (2016). Palliative Care: Time for Action. Oman Medical Journal, 31(3), 161–163.
Aslakson, R. A., Curtis, J. R., & Nelson, J. E. (2014). The changing role of palliative care in the ICU. Critical Care Medicine, 42(11), 2418–2428. doi:10.1097/CCM.0000000000000573
Centers for disease control (2015). Nursing home statistics.
Chover-Sierra, E., Martínez-Sabater, A., & Lapeña-Moñux, Y. R. (2017). An instrument to measure nurses’ knowledge in palliative care: Validation of the Spanish version of Palliative Care Quiz for Nurses. PloS One, 12(5), e0177000.
Cimino, N., Lockman, K., Grant, M, & Lynn McPherson, M. (2016). Knowledge, skills and attitudes in caring for older adults with advanced illness among staff members in long-term care and assisted living facilities: An educational needs assessment.American Journal of Hospice and Palliative Medicine, 33(4), 327-334.
Dumanovsky, T., Augustin, R., Rogers, M., Lettang, K., Meier, D. E., & Morrison, R. S. (2016). The growth of palliative care in U.S. hospitals: A status report. Journal of Palliative Medicine, 19(1), 8–15.
Goldonowicz, J. M., Runyon, M. S., & Bullard, M. J. (2018). Palliative care in the emergency department: an educational investigation and intervention. BMC Palliative Care, 17(1), 43.
Hart, N., Udarbe, O., & Waldo, M. (2018). Risk factors for readmission in patients with heart failure.
Hughs, M. & Smith, T. (2014). The growth of palliative care in the united states. The Annual Review of Public Health. 35-459-75.
Jenko M, Adams JA, Johnson CM, Thompson JA, Bailey DE Jr. (2015). Facilitating palliative care referrals in the intensive care unit: A pilot project. Dimensions of Critical Care Nursing: DCCN,. 34(6), 329-339.
Melnyk, B. M., & Fineout-Overholt, E. (2019). Evidence-based practice in nursing and nursing research:Appraisal, synthesis, and generation of evidence (7th ed.). St. Louis, MO: W. B Saunders.
Mor, V., & Teno, J. M. (2016). Regulating and paying for hospice and palliative care reflections on the Medicare hospice benefit. Journal of Health Politics, Policy & Law, 41(4), 697-716.
Mosoiu, D., Mitrea, N., & Dumitrescu, M. (2018). Palliative care in Romania. Journal of Pain and Symptom Management, 55(2), S67-S76.
O’Reilly, M., Larkin, P., Conroy, M., Twonmey, F., Lucey, M., Dunne., C & Meagher., D. (2016). The impact of a novel tool for comprehensive assessment of palliative care (MPCAT) an assessment outcome at 6- and 12- month follow up. Journal of Pain and Symptom Management, 52(1), 107-116.
Pajnkihar, M., McKenna, H. P., Štiglic, G., & Vrbnjak, D. (2017). Fit for practice: Analysis and evaluation of Watson’s theory of human caring. Nursing Science Quarterly, 30(3), 243-252.
Perumalswami, C. R., Mullangi, S., & Jagsi, R. (2019). The role of Medicare reimbursement in determining access to palliative radiotherapy during hospice care. JAMA Oncology, 5(9), 1257-1258.
Smets, T., Pivodic, L., Piers, R., Pasman, H., Engels, Y., Szczerbińska, K., Kylänen, M., Gambassi, G., Payne, S., Deliens, L., & Van den Block, L. (2018). The palliative care knowledge of nursing home staff: The EU FP7 PACE cross-sectional survey in 322 nursing homes in six European countries. Palliative Medicine, 32(9), 1487–1497.
Tan, A. (2019). Models of palliative care in long-term care: A integrative review. International Journal of Caring Science, 12(2), 892-905.
Taylor, G. H., Krakauer, E. L., & Sanders, J. J. (2020). “Find out what they lack, try to provide”: A qualitative investigation of palliative care services adapted to local need in a low-resource setting. Journal of Palliative Medicine.
WHO. (2018). Palliative care: Key facts.