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



Pages:     | 1 |   ...   | 19 | 20 || 22 | 23 |   ...   | 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 21 ] --

Chapter Summary The ICP has embedded into GP practices to varying degrees. Peer support and CQI are essential to ICP embeddedness, with those who have a strong peer support using more ICP interventions and getting better outcomes for patients in terms of place of death. CQI has contributed to practices significantly increasing their palliative care registrations, preference discussions and LCP use across the locality. Thus the ICP works as it is increasing intervention use (apart from ACP and anticipatory medication which will be discussed elsewhere in the thesis) and it works particularly well for those practices that have strong peer support mechanisms and CQI sessions. Furthermore, the ICP itself is a mechanism which provides interventions; intervention use predicts some of the variance in place of death, thus showing that the ICP works as a palliative care pathway. Finally, interviews highlighted that uptake of commissioned services was variable. This was attributed to personal circumstances and needs yet does not necessarily reflect lack of service value.

Programme theory 1 stated that some GP practices will have better outcomes in terms of place of death than others (context) due to use of interventions (mechanism). This programme theory has been expanded and refined. Some GP practices (Practices D, E and I) do have better outcomes than others in terms of place of death, which is predicted by intervention use. However, there are also other essential mechanisms such as peer support and CQI.

The next chapter focuses on the first intervention in the ICP, palliative care registration. This intervention is crucial, as it allows health care professionals to identify appropriate patients and work within a palliative care framework and to administer further interventions from the ICP such as preference discussions, ACP and LCP.

Chapter 5: Identifying and registering

–  –  –

Palliative care registration is the first step in engaging with the ICP and allows access to further appropriate interventions; palliative care registrations can thus be considered as a measurable proxy for early identification and ICP use. In line with national policy (Department of Health 2008) one of the key aims of the ICP was to identify palliative care patients within 6 months of the end-of-life and place them on the practice palliative care register. This leads to the use of ICP interventions such as OOH notifications and ACP. It also allows health care professionals to use the traffic light system to identify when patients are declining and allows for more responsive, comprehensive and individualised care in the patient’s preferred setting, where possible. In turn, this early identification can lead to a good death (Department of Health 2008). A second aim of the ICP was to identify and register all palliative care patients, regardless of diagnosis, with a specific focus on increasing the registration of non-cancer patients. This was due to the acknowledgement within the locality that non-cancer palliative care patients were rarely identified early. This is also particularly important as population based studies using random samples of deaths and bereaved carer reports indicate that there are more symptom issues in the last year of life in those suffering from progressive non-cancer diseases than those suffering from cancer (Higginson 1997).

This is due to the more extended trajectory of decline in non-cancer illnesses (Murray, Boyd et al. 2005). This suggests that non-cancer patients will rely heavily on palliative care symptom control; the palliative care register identifies these patients and highlights them to health care professionals who can meet their needs.

This chapter will describe CMOCs focused on the registration of palliative care patients in order to address the research questions and programme theory below.

Initial questions asked of the data The programme theory and subsidiary questions that this chapter focuses on were first stated in the methodology chapter and are reiterated below.

 Programme theory 2: Palliative care registrations should increase (outcome) due to a focus on identifying patients early using the palliative care register (mechanism) in a health care domain that appreciates the palliative care needs of patients (context).

- Are palliative care registrations increasing in the locality and if so

–  –  –

- Are both cancer and non-cancer patients appropriately put onto the palliative care register?

CMOC1 focuses on palliative care registrations for all palliative care patients regardless of disease type and explains how this is affected by the consensus of a palliative care definition in the locality. CMOC2 investigates the differences between cancer and non-cancer deaths on the palliative care register and the stress associated with non-cancer registrations. Supporting CMOC2, CMOC3 elucidates the anxieties health care professionals have about over populating the palliative care register with elderly and frail care home residents who have non-cancer illnesses.

CMOC4 explains the recent increase in non-cancer registrations from 2011 to 2012.

CMOC1 – Palliative care registrations Outcome: Increase in all palliative care registrations from 2008 to 2012 As discussed in relation to the embeddedness of the ICP, palliative care registrations are significantly increasing over time; a one-way repeated measures ANOVA was conducted to compare numbers of palliative care registrations from 2008 to 2012, using Death Audit data. Mauchly’s Test of Sphericity was significant (p.05), meaning that sphericity was not assumed and Greenhouse-Geisser values are reported. There was a significant effect of time on palliative care registrations (F(2.74, 30.17) = 9.93, p.001,  p = 0.47), indicating a large effect (Cohen 1988).





The means showed an overall increase in palliative care registrations from 2008 to 2012, therefore it can be concluded that palliative care registrations have increased.

Mechanisms: The decision to register patients Presented below are two mechanisms which work at different levels – the individual level, which contributes to the second mechanism which is at the team level.

Individual level ‘Would you be surprised if this patient was to die in the next 6 months?’ (The National Gold Standards Framework Centre 2009) (resource) is used by health care professionals in the locality to assess suitability of a patient for the palliative care register. This resource increases individual health care professionals’ confidence to suggest palliative care patients for registration at the MDT meeting (reasoning).

GP2 (FG2): “I think it’s one of the things that the palliative care pathway helped us with, in creating our palliative care registers we had to question, we had to ask ourselves, would you be surprised if this person died within six months? And that most certainly helped me define who I had previously would not have defined as palliative care… so I think that the pathway has helped that definition but that’s a local phenomenon I think.” The surprise question is a resource that health care professionals can use in isolation to make decisions about individual patients. If a health care professional believes that the patient may die in the next 6 months then they should suggest them for registration at the next MDT meeting.

Team level The surprise questions prompts individuals to make a decision about whether to suggest a patient for palliative care registration at the MDT meeting. The support that these meetings provide for health care professionals was evident in FG2. The social care lead in FG2 described how she felt that MDT meetings provided support by providing safety.

Social care team lead (FG2): “I think it’s strength in numbers isn’t it, with support for each other as well as safety. It, it’s safer, it’s a safer way to practice all round if you’re making multidisciplinary decisions.” In FG3 support in the palliative care MDT meetings was also described as nonhierarchical; with nurses sometimes providing support for GPs. Palliative care MDT meetings (resource) provide non-hierarchical support for health care professionals which they value highly. Decisions about palliative care registrations take place in these supportive MDT meetings, thus enhancing the confidence of health care professionals in deciding that the patient is appropriate for palliative care registration and removal from unhelpful life prolonging treatment (reasoning).

GP1 (FG1): “And what I think is you grow in confidence as a GP with your team and if the whole teams saying the same thing you feel more empowered to take control and confidently disconnect them from unhelpful (life prolonging) hospital appointments” Community matron (FG1): “I think it (MDT meeting) gives you that permission to say, right where do we stop, you know? And it’s about quality of life, not length of life and it’s about having that conversation with the patient to say, you know what do you want out of this? You know, the chemotherapy isn’t going to make you better? You know? It, it’s going to make them feel rotten anyway, so what do they want out of it? …But I think it allows you to, like GP1 says, (MDT working and meetings) gives you that confidence to have those conversations.” Community matron 2 (FG1): “I think as a primary health care team member, when we meet and discuss our patients who are on that register, it makes, makes you talk about them a bit more than you would have done without it. You know you, it allows you to, erm, you know, once a week or once a fortnight, depending on how often you hold your meetings, it allows you to bring those patients and to, you know, and they’re not forgot about, and both the GPs and the nurses and everybody that’s involved with it can share their views and concerns in a structured way, so I think in that way its good.” The GP and community matron felt that MDT meetings gave them confidence to operate within a palliative care framework where appropriate (reasoning). Thus, health care professionals’ reasoning is being changed in response to the MDT meetings that the ICP provides (resource), to have increased confidence that a patient is appropriate for palliative care (reasoning) and registration.

To summarise the mechanisms, at the individual level the surprise question (resource) increases health care professionals’ confidence to suggest a palliative care patient for registration at the MDT meeting (reasoning). This mechanism triggers the next, which operates at the team level; MDT meetings (resource) then provide additional support and further enhanced confidence that a patient is appropriate for palliative care (reasoning). Health care professionals’ reasoning is being changed to be confident that the patient is appropriate for palliative care in response to resources that the ICP provides, both for the health care professional working in isolation (surprise question) and then as part of a MDT (MDT meeting).

Confidence can be related to self-efficacy, which is the perceived ability to perform a task (Bandura 1977). It has been shown to be an underlying mechanism in a wide range of behaviours (O'Leary 1985, Strecher, DeVellis et al. 1986, Yalow and Collins 1987, Bandura 1991) and can reasonably be linked to the increase in confidence seen in health care professionals in this CMOC.

The ICP offers many resources which can be used in different ways – for example in isolation (the surprise question) or collaboratively (the MDT). Thus it is sometimes impossible to disentangle the different elements of the ICP because they have a synergistic effect on one another. For example, in isolation, the surprise question or MDT meetings may not result in a sufficient increase in confidence to register a patient. Therefore either the surprise question or MDT meetings in isolation provide limited explanatory potential for the increase in all palliative care registrations.

Context: Consensual definitions In 2008, the End of Life Care Strategy (Department of Health 2008) was published which made palliative and end-of-life care a priority. The locality absorbed this information and made it applicable through the design and use of the palliative care registers. The publication of this policy and implementation of the ICP prompted the need for enhanced understanding of the definitions of palliative and end-of-life care. Individuals living with progressive and complex illnesses eventually experience the transition from treatment focused on stabilisation, even remission of their disease, to treatment focused on palliation (Thompson, McClement et al.

2006). FG2 highlighted that some health care professionals are still not confident in identifying when curative care should become palliative care, resulting in less palliative care registrations.



Pages:     | 1 |   ...   | 19 | 20 || 22 | 23 |   ...   | 49 |


Similar works:

«Living in Christ, Starving the Flesh “But put on the Lord Jesus Christ, and make no provision for the flesh in regard to its lusts.” Romans 13:14 NASB Our verse is Romans 13:14. This precious Word from God specifically addresses Christians and contains two commands— “put on the Lord Jesus Christ” and “make no provision for the flesh.” However, the verse first introduces the commands by calling the Christian’s attention to a contrast. Note the conjunction “But” at the...»

«Teenage Dreams: can adolescent aspirations be used to inform new conservation initiatives in Kazakhstan? Sophie Elliott SEPTEMBER 2014 A thesis submitted for the partial fulfilment of the requirements for the degree of Master of Science at Imperial College London Submitted for the MSc in Conservation Science DECLARATION OF OWN WORK I declare that this thesis: “Teenage Dreams: can adolescent aspirations be used to inform new conservation initiatives in Kazakhstan?” is entirely my own work...»

«Volume 23 Issue 1 6th February 2015 Editors Mr Felix Patton Mrs Jenny Walker Mrs Chess Forster And so High School begins. WHAT’S ON AT RSC FEBRUARY 10th: Swimming Sports 11th 13th: Yr 12 O / Ed Camp 17th: Yr 7 Parent Info Night Intermediate Sport 19th : Yr 10 12 School Photos 20th: Yr 7 9 School Photos 25th: Yr 7 Luncheon 25th 27th: Yr 11 O / Ed Camp Cathedral Range MARCH 4th 6th: Yr 10 O / Ed Camp 5th: Yr 7 Sport 9th: LABOUR DAY SCHOOL CLOSED 13th: Yr 11 Outdoor Ed Edithvale-Seaford Wetlands...»

«Trial Tactics Getting the Best Results from Opening Statements: Dennis Ellis Paul Hastings LLP Los Angeles, CA Hon. J. Michelle Childs District Judge, District of South Carolina Greenville, SC Ricardo Woods Burr & Forman LLP Mobile, AL Hon. Thomas Durkin District Judge, Northern District of Illinois Chicago, IL GETTING THE BEST RESULTS FROM OPENING STATEMENTS By David T. Lopez – December 13, 2011 –“Verdict” (Trial Practice Committee Journal) Summer 2011, 25:3 Sometimes, when browsing...»

«GRAND PORT MARITIME DU HAVRE REGLEMENT LOCAL POUR LE TRANSPORT ET LA MANUTENTION DES MARCHANDISES DANGEREUSES REGLEMENT LOCAL POUR LE TRANSPORT ET LA MANUTENTION DES MARCHANDISES DANGEREUSES DANS LE PORT DU HAVRE 2014 Arrêté préfectoral du 20 décembre 2013 Règlement rédigé conformément aux conclusions des études de dangers exigée par l’article L551-2 du Code de l’Environnement. 1 GRAND PORT MARITIME DU HAVRE REGLEMENT LOCAL POUR LE TRANSPORT ET LA MANUTENTION DES MARCHANDISES...»

«A N T AG O N I S T I C AU T H O R I T I E S A N D T H E C I V I L P O L I C E I N S Ã O PAU L O, B R A Z I L Graham Denyer Willis Massachusetts Institute of Technology Abstract: This article draws on participant observation research in a Civil Police station (delegacia) in the city of São Paulo, Brazil, to disentangle existing notions of police resistance to democratic change. Through processes such as “talk of castigation,” the Civil Police reproduce three kinds of authority—public,...»

«Understanding Hodgkin Lymphoma (also known as Hodgkin’s Disease) A guide for patients and families 2 NOTES 1 CONTENTS PAGE The Leukaemia Foundation 4 An Introduction: Getting to know your bone marrow, stem cells and blood 8 The lymphatic system 14 What is lymphoma? 15 What is Hodgkin lymphoma? 15 What causes Hodgkin lymphoma? 16 What are the signs and symptoms of Hodgkin lymphoma? 17 Which doctor? 18 How is Hodgkin lymphoma diagnosed? 18 Types of Hodgkin lymphoma 20 Treatment 27 Stem cell...»

«International Council on Monuments and Sites ICOMOS International Union for Conservation of Nature IUCN Reactive Monitoring Mission to the Tasmanian Wilderness, Australia 23 29 November 2015 Mission Report Tilman Jaeger (IUCN) Christophe Sand PhD (ICOMOS) ii TABLE OF C O N T E N T S A C K N O W L E D G E M E N T S LIST OF ABBREVIATIONS AND ACRONYMS EXECUTIVE SUMMARY 1. BACKGROUND TO THE MISSION 2. LEGAL AND MANAGEMENT FRAMEWORK 3. IDENTIFICATION AND ASSESSMENT OF ISSUES 3.1 The on-going...»

«Author: William Henry Long (1839-1896) Text type: Glossary D ate of composition: 1886 Editions: 1886.Source text: Long, William Henry. 1886. A Dict ionary of t he Isle of W ight dialect, and of prov incialisms used in t he island; t o w hich is appended t he Christ mas Boy s’ play, an Isle of W ight “Hooam Harv est,” and songs sung by t he peasant ry ; forming a t reasury of insular manners and cust oms of fift y y ears ago. London: Reeves and Turner. e-text Access and transcription: N...»

«Application Pack Background information The Tricycle The Tricycle opened in a converted Foresters’ Hall on the Kilburn High Road, London, in 1980. Following a fire in 1987, the theatre was re-built and the front of house facilities were enhanced and expanded. In 1998 a new cinema building with additional facilities was completed alongside the theatre with the help of funds from the National Lottery. The Tricycle now comprises a 235 seat theatre, a 300 seat cinema, a large rehearsal studio...»

«WHO/CDS/CSR/GIP/2004.3 Vaccines for pandemic influenza Informal meeting of WHO, influenza vaccine manufacturers, national licensing agencies, and government representatives on influenza pandemic vaccines SUMMARY REPORT 11–12 November 2004 Geneva, Switzerland Department of Communicable Disease Surveillance and Response Global Influenza Programme CONTENTS Introduction 1. Conclusions Conclusions from the meeting Summary conclusions from the working groups 2. Summary of presentations and...»

«19. The Tempest Shakespeare's last play can be read as a metaphor (in poetry, magic, music and masque) for his own nature, the elements of which are divided into a cast of characters both natural and spiritual, a last supreme attempt to impose a resolution upon those conflicts which had fuelled all the great works. Miranda's first speech is a strong condemnation of Prospero for using his Art to cause the shipwreck she has just witnessed : Had I been any god of power, I would Have sunk the sea...»





 
<<  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.