WWW.DISSERTATION.XLIBX.INFO
FREE ELECTRONIC LIBRARY - Dissertations, online materials
 
<< HOME
CONTACTS



Pages:   || 2 | 3 | 4 | 5 |   ...   | 49 |

«Citation: Dalkin, Sonia (2014) The Realist Evaluation of a Palliative Integrated Care Pathway in Primary Care: What Works, For Whom and in What ...»

-- [ Page 1 ] --

Citation: Dalkin, Sonia (2014) The Realist Evaluation of a Palliative Integrated Care Pathway

in Primary Care: What Works, For Whom and in What Circumstances? Doctoral thesis,

Northumbria University.

This version was downloaded from Northumbria Research Link:

http://nrl.northumbria.ac.uk/18251/

Northumbria University has developed Northumbria Research Link (NRL) to enable users to

access the University’s research output. Copyright © and moral rights for items on NRL are retained by the individual author(s) and/or other copyright owners. Single copies of full items can be reproduced, displayed or performed, and given to third parties in any format or medium for personal research or study, educational, or not-for-profit purposes without prior permission or charge, provided the authors, title and full bibliographic details are given, as well as a hyperlink and/or URL to the original metadata page. The content must not be changed in any way. Full items must not be sold commercially in any format or medium

without formal permission of the copyright holder. The full policy is available online:

http://nrl.northumbria.ac.uk/policies.html The Realist Evaluation of a Palliative Integrated Care Pathway in Primary Care: What Works, For Whom and in What Circumstances?

Sonia Michelle Dalkin PhD The Realist Evaluation of a Palliative Integrated Care Pathway in Primary Care: What Works, For Whom and in What Circumstances?

Sonia Michelle Dalkin A thesis submitted in partial fulfilment of the requirements of the University of Northumbria at Newcastle for the degree of Doctor of Philosophy Research undertaken in the Faculty of Health and Life Sciences and in collaboration with the NHS North of Tyne February 2014 Abstract Background: Finding effective ways to care for people with palliative care needs is a national priority. A primary care locality has developed and implemented an Integrated Care Pathway (ICP) for those with life limiting illnesses. It focuses on identifying patients early, regardless of disease type, and uses proactive and patient centred interventions to plan for a good death. Although palliative care pathways present a promising practice framework, the literature does not allow for an assessment of how and when they work best. This thesis aimed to explain which parts of the ICP worked best, for whom and in what circumstances. Design: Realist evaluation was used to guide the analysis of multiple data strands: quantitative data from the GP practices; interviews with palliative care patients and bereaved relatives; bereaved relatives and matched health care professional questionnaires; focus groups with health care professionals; consultation recordings with palliative care patients and their GPs. Results: The results of this study are multifaceted, and focus on the conditions of successful implementation, such as the presence of a champion; palliative care registration decisions for all diagnoses and the importance of leadership and peer support; advance care planning, including the roles of mental capacity and time constraints; communication in consultations and the role of patient and GP traits; and using open multicomponent communication strategies to facilitate home deaths. Discussion: A realist approach has exposed how the ICP implementation has led to positive practice and patient level outcomes. The ICP can be construed as a translational tool, which enables the operationalisation of policy directives on shared decision making, proactivity and patient centeredness in primary care. In the context of palliative care, this study allows important reconceptualisations of shared decision making and advance care planning to be presented.

Contents

Abstract

Contents

List of tables and figures

Glossary of Abbreviations

Acknowledgements

Declaration

Introduction

Background

Formulation of the research questions

Protocol publication

Flow of the thesis

Chapter 1: Key issues in palliative and end-of-life care

Palliative care: historically and in practice

Preferences in end-of-life care addressed through palliative care

Difficulties in discussing death and dying

The political mandate

Important concepts from palliative care policies

Proactive care

Patient centred care

Shared decision making

Difficulties in translating policy in to practice

An ageing population

Time constraints

Communication surrounding death and dying

Litigation in palliative care

Definitions of palliative and end-of-life care

Aids to translating policy into practice

Continuous Quality Improvement

Diffusion of Innovation

Normalisation Process Theory

Summary of aids to translate policy into practice

Chapter Summary

Chapter 2: Integrated Care Pathways

What is an integrated care pathway?

The Liverpool Care Pathway for the Dying Patient

The Integrated Care Pathway under study

Advance palliative care registration

Preference discussions and advance care planning

Home and hospice care

Out of Hours notifications

Traffic light system

Multidisciplinary Team Meetings

Anticipatory care medication





The Liverpool Care Pathway for the Dying Patient

Palliative Care Quality Visits – Continuous Quality Improvement

Evidence of Integrated Care Pathway effectiveness in palliative care

Implementation of the Gold Standards Framework to enhance palliative care services What is known so far?

Chapter Summary

Chapter 3: Methodology

Realism

Questions of ontology, epistemology and methodology in realism

Theoretical framework: realist evaluation

Social Programmes

• Context

• Mechanism

• Outcome

How is a social programme evaluated?

Research questions and programme theories

Data Collection and Analysis

Framework

The operationalisation of the data collection into realist evaluation

Ethical approval

Chapter Summary

Findings chapters

Chapter 4: Embeddedness of the Integrated Care Pathway as a new initiative.......... 117 Initial questions asked of the data

CMOC1 – Integrated Care Pathway intervention use and preferred place of death. 118 Outcomes: Intervention use predicts presumed preferred place of death............. 118 Mechanism - The ICP and increasing perceived capability and capacity............ 120 Context: Palliative care at the top of the political agenda

Summary

CMOC2 – Commissioned services in the ICP

Outcome: Variable commissioned service use

Mechanism: Increased support for palliative care patients who need it............... 123 Context: Increased need for palliative care services

Summary

CMOC3 – Continuous quality improvement and intervention use

Outcome: Increased use of Integrated Care Pathway interventions

Mechanism: Continuous Quality Improvement

Context: Proactive and patient centred care

Summary

CMOC4 (I) – Peer support, leadership and embeddedness of the ICP

Outcome: Embeddedness - three high performing practices

Mechanism: Opinion leaders and a champion

Context: Shared nursing team on site which facilitates MDT meetings............... 152 Summary

CMOC4 (II) – Low peer support and perceived detachment

Outcome: Less use of the palliative care register and other interventions........... 155 Mechanism: Lack of communication

Context: Detachment from the ICP and locality

Summary

Chapter Summary

Chapter 5: Identifying and registering palliative care patients

Initial questions asked of the data

CMOC1 – Palliative care registrations

Outcome: Increase in all palliative care registrations from 2008 to 2012............ 164 Mechanisms: The decision to register patients

Context: Consensual definitions

Summary

CMOC2 – Registering non-cancer patients

Outcome: Less non-cancer patients than cancer patients registered

Mechanism: Stress when registering a non-cancer patient

Context: Unpredictable illness trajectories

Summary

CMOC3 – Care home residents

Outcome: Less non-cancer patients than cancer patients registered

Mechanism: Anxiety about registering care home residents

Context: Elderly non-cancer patients’ prognosis is difficult to predict................ 186 Summary

CMOC4 – Recent increase in non-cancer registrations

Outcome: Significant increase in non-cancer registrations from 2011 to 2012.... 188 Mechanism: Legitimation through education

Context: Changes in cause of death and palliative care for all

Summary

Chapter Summary

Chapter 6: Preference discussions and the locality advance care plan.................. 198 Initial questions asked of the data

CMOC1 – Markers for initiating preference discussions

Outcome: Increase in preference discussions

Mechanism: Health care professionals’ desire to be patient centred

Context: A change in condition or increased needs

Summary

CMOC2 – False hope can prevent preference discussions

Outcome: Preference discussions can occur late

Mechanism: Preference discussions can dash patients’ hopes for recovery......... 209 Context: False hope from secondary care

Summary

CMOC3 – Time constraints in primary care

Outcome: Preference discussions do not predict use of the locality advance care plan Mechanism: Additional paper work generated from the locality advance care plan Context: Time constraints in primary care

Summary

CMOC4 – The Mental Capacity Act and the locality advance care plan................. 217 Outcome: No significant increase in locality advance care plans from 2009 to 2012 Mechanism: The mental capacity act and instability of capacity

Context: The locality advance care plan is to be used with those who have capacity to engage

Summary

CMOC5 – A change to the advance statement from Deciding Right

Outcome: The locality changed to the use of the advance statement

Mechanism: The advance statement

Context: The locality advance care plan is not user friendly

Summary

Chapter Summary

Chapter 7: Facilitating difficult conversations in palliative care

Initial questions asked of the data

CMOC1 - High monitor and low blunter

Context: Information seekers: GP-A and patient 1 (Mary)

Mechanism: Advance Care Planning

Outcome: Locality advance care plan reviewed

Summary

CMOC2 – High monitors and high blunters

Context: Information seeker or avoider? GP-B and patient 2 (John).............. 240 Mechanism: Advance Care Planning

Outcome: Advance care planning does not occur

Summary

CMOC3 - Low monitor and low blunter

Context: Low monitoring and blunting scores: GP-C and patient 3 (Susan)....... 245 Mechanism: Advance Care Planning (not firing)

Outcome: Advance care planning does not occur

Summary

Formulation of a new CMOC

Chapter Summary

Chapter 8: Facilitating a home death

Initial question asked of the data

CMOC1 – Caring for a loved one who is dying

Outcome: Increase in home deaths

Mechanism: Easily accessible palliative expertise

Context: Death is hidden

Summary

CMOC2 – Open communication strategies to increase ‘home’ deaths

Outcome: Increase in ‘home’ deaths

Mechanism: Open communication strategies (preference discussions and ACP) 273 Context: Family and carers knowledge of the patient’s preferences

Summary

CMOC3 – Care home deaths

Outcome: No significant increase in care home deaths

Mechanism: Fear of reprimand and consequences of a ‘wrong’ decision............ 284 Context: Litigious society

Summary

Chapter Summary

Chapter 9: Discussion

The overall programme theory; the ICP as a translational tool

Shared Decision Making

Patient centred care

Proactivity

Study findings in relation to the current literature on ICPs

Implications for practice

Challenges

Limitations

Future research

Conclusion

References

List of tables and figures Figure 1: Context, Mechanism and Outcome Configurations in realist evaluation........... 87 Figure 2: The operationalisation of the method

Figure 3: A correlation between the number of ICP interventions administered per patient and the number of patients who achieved their presumed preferred place of death........ 119 Figure 4: CMOC1, ICP intervention use and preferred place of death

Figure 5: CMOC2, commissioned services in the ICP

Figure 6: Mean number of palliative care registrations between 2007 and 2012, using Death Audit data.

Figure 7: Mean number of preference discussions between 2009/10 and 2011/12, using MIQUEST data.

Figure 8: Anticipatory medication prescriptions from 2009/10 to 2011/12.

Figure 9: Mean number of LCP use between 2009/10 and 2011/12, using MIQUEST data.

Figure 10: CMOC3, CQI and intervention use

Figure 11: CMOC3 (I), peer support and embeddedness of the ICP.

Figure 12: The number of palliative care registrations in Practice C from 2007 to 2012, using Death Audit data

Figure 13: CMOC3 (II), low peer support and perceived detachment

Figure 14: CMOC1, palliative care registrations

Figure 15: The number of cancer deaths in total compared to the number of cancer deaths that were on the palliative care register, for 2011, using Death Audit data.

Figure 16: The number of non-cancer deaths in total compared to the number of noncancer deaths that were on the palliative care register, for 2011, using Death Audit data.

Figure 17: Ratios of palliative care registered to not palliative care registered deaths for those with cancer and non-cancer for each practice in 2011, using Death Audit data.... 176 Figure 18: CMOC2, registering non-cancer patients

Figure 19: CMOC3, care home residents.

Figure 20: Recent increases in non-cancer registrations



Pages:   || 2 | 3 | 4 | 5 |   ...   | 49 |


Similar works:

«What are the roots causes of entrepreneurial failure ? An exploratory study using cognitive mapping approach Nabil KHELIL Assistant Professor University of Caen Normandie CREM-CNRS-UMR 6211, France Campus 4, 19 rue Claude Bloch, 14000 Caen. nabil.khelil@unicaen.fr 00 33 02 31 56 58 27 Abstract Despite the contributions of previous studies, there has been little attention given to investigate how new ventures fail. This paper seeks to recognize the causes of entrepreneurial failure by employing...»

«Film-Philosophy, 12.1 April 2008 The Practice of Strangeness: L’Intrus – Claire Denis (2004) and Jean-Luc Nancy (2000)1 Mar t ine Beugnet University of Edinburgh A child of the era of decolonization, Claire Denis grew up in various regions of France’s subSaharan colonial lands, and was brought back to the ‘métropole’ as a teenager in the 1960s. She has thus had a double practice of foreignness, abroad, and in her ‘own’ country, which she did not know and where, in similar yet...»

«Patient information from the BMJ Group Fertility problems: what treatments work? Definitions of fertility problems vary in different countries. But couples are usually diagnosed as having fertility problems if they have been trying for a baby without success for between one and two years. If you're a woman aged over 35 your doctor might want to do some tests and perhaps offer treatment after as little as six months. For people trying to have a child, facing the possibility of fertility problems...»

«Fundraising Ideas That Work for Grassroots Groups by Ken Wyman, CFRE* Director Ken Wyman and Associates Inc Consultants in Fundraising, Volunteerism, and Communication 64B Shuter Street Toronto, Ontario M5B 1B1 (416) 362-2926 * Certified Fundraising Executive Voluntary Action Program Department of Canadian Heritage Ottawa 1995 Note: This is an updated, expanded and largely revised version of A Guidebook to Fundraising for Disabled Persons' Groups, published in 1988 by the Disabled Persons'...»

«OCTOBER TERM, 2007 1 (Slip Opinion) Syllabus NOTE: Where it is feasible, a syllabus (headnote) will be released, as is being done in connection with this case, at the time the opinion is issued. The syllabus constitutes no part of the opinion of the Court but has been prepared by the Reporter of Decisions for the convenience of the reader. See United States v. Detroit Timber & Lumber Co., 200 U. S. 321, 337.SUPREME COURT OF THE UNITED STATES Syllabus ALI v. FEDERAL BUREAU OF PRISONS ET AL....»

«Seasons greetingsseasons greetings The Swimming Pool April 2016 Issue 83 Newsletter for the SWIMS Network The Editorial Team Sam Burgess Inside this issue Pam Geldenhuys Lucy Gilham Thames Valley & Wessex Easter Meeting 2 Ruth Jenkins #UKMedLibs 3 Cathy Marsden Completing an MSc Econ at Aberystwyth University 4 Jessica Pawley One year on for the Patient and Public Information 5 Imelda Winn Task & Finish Group House of Commons Library Open Day 6 National Libraries Day 7 Spare some change. 7...»

«STAFF REPORT ACTION REQUIRED 410 – 446 Bathurst St Zoning Amendment Application Preliminary Report April 18, 2013 Date: Toronto and East York Community Council To: Director, Community Planning, Toronto and East York District From: Ward 19 – Trinity-Spadina Wards: Reference 13 124400 STE 19 OZ Number: SUMMARY This application proposes to demolish the existing non-residential buildings and construct a new 3-storey commercial building having a total gross floor area of approximately 12,000...»

«MCAFEE SCHOOL OF THEOLOGY STYLE GUIDE REVISED 2012 based on Turabian, Kate L. A Manual for Writers of Term Papers, Theses, and Dissertations, 7th ed. Chicago: The University of Chicago Press, 2007.. Nancy L. deClaissé-Walford McAfee School of Theology Atlanta, Georgia SPRING 2012 TABLE OF CONTENTS SECTION 1: PARTS OF A PAPER 1.1 Title Page 1.2 Page Numbering 1.3 Margins 1.4 General Formatting Issues 1.4.1 Font Size 1.4.2 Line Spacing 1.4.3 Indenting Paragraphs 1.4.4 Paragraphs 1.4.5 Indented...»

«Newport Care Homes Directory Introduction Welcome to the Care Homes Directory for Newport This Directory only lists those care homes within the boundaries of Newport, although the City Council also supports residents in other care homes outside Newport. Details of care homes in other areas are available from the relevant Local Authorities. If you are thinking of moving to a care home you are faced with some very important decisions and choices. You will need information about the choices...»

«From Traumascapes to Touristscapes: “War Tours” in Sarajevo and Vukovar Patrick Naef Abstract If the link between war and tourism has already received considerable academic and media attention, the spatial representation of war in the tourism sector is still emerging in the fields of cultural geography and anthropology. In this paper I seek to explore the rehabilitation and touristification of sites traumatised by war – which I have approached using the concept of Traumascape (Tumarkin,...»

«Proceedings of the European Information Security Multi-Conference (EISMC 2013) National Password Security Survey: Results K. Helkala1 and T.H. Bakås2 1 Norwegian Defence Cyber Academy and Gjøvik University College 2 Norwegian Centre for Information Security e-mail: kirsi.helkala@gmail.com, tone@norsis.no Abstract Research, especially in the early 21st century, has shown that education is needed to change people’s behaviour regarding password generation, management and storage. As our daily...»

«Swisher 1 Reigniting the Light: Reaching Catholic Young Adults in the Digital World Let’s Start from the Top As a church, we have come a long way with youth ministry programs since the 1970s, growing and adapting to the needs of our youth. This, too, applies to campus ministry programs within our Catholic schools. Administrators are beginning to understand the importance of developing one's faith during adolescence, alongside academics and extra-curricular activities; the need to live one's...»





 
<<  HOME   |    CONTACTS
2016 www.dissertation.xlibx.info - Dissertations, online materials

Materials of this site are available for review, all rights belong to their respective owners.
If you do not agree with the fact that your material is placed on this site, please, email us, we will within 1-2 business days delete him.