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A Staff Capacity-Building Initiative in Long-Term Care Homes ABSTRACT This article reports a pilot evaluation of Comfort Care Rounds
difficulty in balancing heavy workloads and scheduling logis-
(CCRs)—a strategy for addressing long-term care home staff ’s
tics. Interprofessional team member representation was sought
palliative and end-of-life care educational and support needs.
but was not consistent. Study participants recognized the ben-
Using a qualitative descriptive design, semistructured individual
efits of attending; however, they provided feedback on how the
and focus group interviews were conducted to understand staff
scheduling, content, and focus could be improved. Overall, study
members’ perspectives and feedback on the implementation and
participants found CCRs to be beneficial to their palliative and
application of CCRs. Study participants identified that effective
end-of-life care knowledge, practice, and confidence. However,
advertising, interest, and assigning staff to attend CCRs facilitated
they identified barriers and recommendations, which warrant on-
their participation. The key barriers to their attendance included
going evaluation. [Journal of Gerontological Nursing, 40(1), 42-48.]
Abigail Wickson-Griffiths, RN, MN; Sharon Kaasalainen, PhD, RN; Kevin Brazil, PhD; Carrie McAiney, PhD; Diane Crawshaw, BA; Mickey Turner, RN, CHPCN(C); and Mary Lou Kelley, PhD, MSW 42
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A
pproximately 44% of residents die in Canadian longterm care (LTC) home settings each year (Canadian Institute for Health Information [CIHI], 2012); therefore, the need to provide high-quality palliative and end-oflife care is warranted. The World Health Organization (WHO; 2014) explains that palliative care is a holistic approach to improving the quality of life for patients who have a life-threatening illness and their family members, through preventing and relieving the patient’s suffering. Ensuring access to quality palliative and end-of-life care is a priority in Canada, as seen through initiatives such as The Way Forward (Canadian Hospice Palliative Care Association [CHPCA] & Quality End-of-Life Care Coalition of Canada, 2014). Given residents’ advanced age, care needs, and desire to remain in their LTC homes until death, these facilities must strategize to ensure delivery of high-quality palliative care (Brazil et al., 2006; Canadian Healthcare Association, 2009; CIHI, 2011). However, studies focusing on LTC home staff’s knowledge regarding the care of dying residents and their families demonstrate an area for growth (Brazil, Brink, Kaasalainen, Kelly, & McAiney, 2012; Ersek, Kraybill, & Hansberry, 1999, 2000). In addition to building knowledge, providing LTC home staff with opportunities for support and reflection on deceased residents must also be addressed (Beck, Törnquist, Bröstrom, & Edberg, 2012). Comfort Care Rounds (CCRs), practiced at two Canadian LTC homes, are a strategy for addressing staff’s palliative and end-of-life care educational and support needs.
CONTEXT Since 2009, four LTC homes have partnered with two Canadian universities to engage in the Improving the Quality of Life for People Dying
in Long-Term Care Homes study (Palliative Alliance, 2014). The study uses a participatory action research approach, by which university researchers work in partnership with the LTC homes, as well as community and national partners, to help improve palliative care approaches, processes, and delivery. A key goal of the study is to educate and empower unlicensed care providers, also called personal support workers (PSWs), to improve the quality of palliative care for LTC home residents and their family members. Other strategies evaluated in this study that focused on improving the quality of life and care for dying residents have been reported previously (Kaasalainen, Brazil, & Kelley, 2012; Landau, Brazil, Kaasalainen, & Crawshaw, 2013; Larocque et al., 2014). The current article reports the pilot evaluation of the CCRs strategy, practiced at two LTC homes in southwestern Ontario, Canada (hereafter referred to as Site 1 and Site 2).
DESCRIPTION OF CCRs In Site 2, CCRs evolved from Pain Rounds, which were attended by licensed nursing staff to share information about resident pain management. As the licensed nursing staff became more knowledgeable, their attendance at the Pain Rounds declined. To attract staff attendance and address their broader interest in palliative care delivery, the Pain Rounds evolved into CCRs. The regional palliative care consultant and a comprehensive advanced palliative care education (CAPCE) trained nurse were responsible for transitioning the Pain Rounds to the CCRs strategy. Approximately 8 months later, the palliative care consultant implemented CCRs at Site 1. During the evaluation period, CCRs were scheduled on a monthly basis, for 30 minutes at Site 1 and 1 hour at Site 2. All members of the interprofessional team and palliative care volunteers were welcomed to attend.
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The home-wide attendees gathered in a central meeting room to discuss resident case-based palliative and end-of-life care issues. Of note, palliative care is recognized by CCRs chairs as a holistic approach to care, which promotes comfort and dignity for individuals with life-limiting illness(es) and their family members (CHPCA, 2014). During CCRs, end-of-life care is usually discussed in the context of the care provided when the resident is actively dying; however, no definite time period for when end-of-life care occurs has been determined in the literature (Powers & Watson, 2008). At Sites 1 and 2, the goal of CCRs is to provide an LTC home-wide forum for staff and palliative care volunteers to engage in case-based discussions about palliative and endof-life care for deceased or dying residents. To meet this goal, the palliative care consultant, CAPCE-trained nurse, and other CCRs leaders (e.g., nurse managers) are responsible for chairing or co-chairing CCRs with interprofessional staff and palliative care volunteers. The CCRs chairs have several roles and responsibilities, including developing an agenda, promoting and advertising CCRs, facilitating discussion, providing education, and disseminating key messages to staff not in attendance. The chairs focus is on providing palliative and end-of-life care education; debriefing opportunities, reflection, and discussion on resident cases; and peer support for staff and volunteers. However, CCRs are intended to meet the learning and reflection needs of the staff and volunteers and are therefore flexible in terms of the content reflected on and discussed. For a summary of the strategy, see Appendix A (available in the online version of this article). In a typical CCRs meeting, the chair will start by reviewing recent resident deaths and then ask and respond to a series of questions to help identify attendees’ learning and
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reflection needs. Examples of questions include: ● What aspects of the end-of-life or after care went well or did not? ● What are the possible reasons this situation went well or did not, and what can be done differently next time? ● How did this end-of-life care experience make you feel? Depending on the topic areas that the attendees respond with, the CCRs chair will then provide educational (i.e., correct misconceptions about or offer optimal care processes, discuss strategies to promote resident and family comfort) and emotional (i.e., affirm attendees’ practices and processes, acknowledge emotions and experiences) support.
METHOD Using a qualitative descriptive design described by Sandelowski (2000), the research team sought to evaluate the implementation, format, process, and outcomes of CCRs. At the time of the pilot evaluation, CCRs were held for approximately 10 months at Site 1 and 18 months at Site 2. With guidance, two research assistants conducted semistructured focus groups and individual interviews with staff and a volunteer from both sites to learn their perspectives. Poster advertisements and wordof-mouth from staff were two strategies used to recruit focus group participants. To gain a variety of perspectives, staff were encouraged to attend the focus groups regardless of their level of participation at the CCRs. Two focus groups were conducted with licensed nurses (n = 18) and three with PSWs (n = 12). In addition, 10 individual interviews were conducted with members of the interprofessional staff and administration, as well as a palliative care volunteer. The interview participants either actively attended CCRs or were involved with its implementation or monthly organization. Prior to the pilot evaluation, an ethics review and approval was ob-
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tained at the university and community levels. Written consent was obtained from all participants. All participants were asked to provide feedback about their CCRs experiences. They were asked about the facilitators and barriers to the implementation, outcomes, and ways to improve CCRs (the interview guide is available upon request from the authors). The focus groups and interviews took between 10 and 45 minutes to complete. The variation in length related to the number of participants and their level of involvement in CCRs. In recognition of their time, participants received a $15 gift card. With permission, the focus group and individual interview discussions were audiorecorded and transcribed. Thematic content analysis was used to interpret the findings (Hsieh & Shannon, 2005). All transcripts were read in their entirety to gain a sense of the entire dataset. Eight of the 10 individual interview transcripts were independently coded by two individuals (A.W.-G., S.K.) to establish a master coding list. Discrepancies were discussed until consensus on a coding framework was reached. One individual (A.W.-G.) coded all transcripts according to the coding framework. Once all of the data were coded, overarching themes that emerged were identified by two individuals (A.W.-G., S.K.).
RESULTS Participants Forty participants took part in the CCRs evaluation. Participants were requested to complete a demographics questionnaire; 39 questionnaires were returned. The majority of participants were women (97.5%) employed as either a licensed nurse (45%) or PSW (35%) with at least 5 years of LTC home work experience (84.6%). Most participants indicated having previous palliative care education (88.8%). Participants also reported having attended on average three
(SD = 3.3) CCRs; however, eight participants had not attended any CCRs. Overview of Findings The analysis of the focus group and individual interview discussions identified several themes, including: facilitators and barriers to implementation and application, the interprofessional approach, perceived outcomes, recommendations for improvement, and overall impressions of CCRs. The main themes are described below. Factors That Facilitate CCRs. Participants suggested several facilitator strategies that helped implement and sustain CCRs, including effective advertising and promotion, management support, and staff interest. At both sites, a combination of methods was used to advertise and encourage staff attendance, including a notice in the education calendar, e-mail reminders, memos, posters in the nursing station, and personal encouragement to attend. In addition, to specifically promote PSW attendance at Site 1, a licensed nursing staff member assigned one PSW to attend CCRs and instructed the staff remaining on the resident unit to cover the work of that individual. Staff identified that managers were often in attendance and personally reminded others to attend CCRs. Staff interest in palliative care was also a key facilitator in promoting attendance at CCRs. Barriers to CCRs. Barriers to planning and implementing CCRs were also identified and included balancing competing demands and resident-care workload, a lack of unit coverage, scheduling difficulties, and lack of awareness and interest in CCRs. Staff recognized that they had to balance competing work demands on the units with attending CCRs. In addition, both sites provided other educational opportunities and in-services, which also needed to be prioritized by staff. A licensed nurse stated:
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It’s trying to get everything accomplished. So that makes it difficult because you are pulled, like, you want to know and you would be a better nurse for it, but you still have the demands that pull you away from the learning.
Participants also voiced concerns that they were not always replaced with other staff when they attended CCRs, leaving remaining staff on the resident unit to manage heavy workloads. Not only did this limit the number of staff who could attend per unit (usually either one licensed nurse or PSW), but it also left staff feeling as though they needed to “catch up” with work on their return. In addition, although effort was put into scheduling CCRs at both sites, challenges were still identified with the selected dates and times. Finally, although the sites used a variety of methods to advertise CCRs and encourage attendance, some staff lacked awareness or were not interested in attending. Interprofessional Approach to CCRs. Increasing interprofessional attendance, especially for PSWs, was a mutual goal of the LTC home sites and the research team. However, neither site had consistent interprofessional team attendance. Despite this lack of attendance, some participants recognized the role that all team members can play in providing palliative care. A palliative care volunteer stated, “I think it’s very valuable. I think it’s valuable to everyone. It’s a continuum of care, not just departmentalized.” In addition, staff at one site believed that an open and safe environment was created for all attendees to share their experiences. It was expected that by encouraging the interprofessional team to attend, they would learn more about each others’ roles in providing palliative and end-of-life care. However, challenges were identified in the interprofessional approach to CCRs. Some staff at one site believed they were losing the depth of nursing-focused discussion by
including other disciplines. In fact, participants at both sites recognized that their discussions had to be more broadly focused to be inclusive of all attendees. Overall, it was difficult to find a discussion focus that would meet everyone’s learning needs. In addition, given that resident care was their first priority, by encouraging PSWs to attend, the licensed nursing staff could not attend and vice versa. It proved difficult to find a time that worked for the majority to attend and achieve interprofessional representation. Perceived Outcomes. When asked about the benefits or outcomes of at-
Improved communication or working relationships among staff members and volunteers was another noted outcome. For example, a participant spoke about how individuals gathered discipline-specific information about residents; however, it was not always well communicated to other staff members. Thus, CCRs provided an opportunity for the interprofessional team to share their unique perspectives on the residents, ultimately improving team communication and knowledge about the residents. PSW empowerment in providing palliative care was another outcome.
Comfort Care Rounds provided an opportunity for the interprofessional team to share their unique perspectives on the residents, ultimately improving team communication and knowledge about the residents.
tending CCRs, participants offered a variety of responses regarding new knowledge, improved confidence and communication, staff empowerment, and chances for debriefing and reflection. Although some participants could not identify any outcomes or changes in practice as a result of participating in CCRs, other participants talked about either refreshing or gaining new knowledge on palliative or end-of-life care approaches. Participants provided examples of learning about physical care during end-of-life, such as oxygen therapy and suctioning; social interventions, such as music therapy and addressing spirituality; and general knowledge about palliative and end-of-life care. Along with new knowledge, some participants also reported an increased confidence in providing palliative and end-of-life care to residents and families.
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Along with increased confidence, a PSW explained that by attending CCRs, she learned how PSWs can be more involved in providing palliative care. She also noted that licensed nursing staff had a greater awareness of the potential of the PSW role: It gave us an opportunity to find out what we could do at the PSW level to help assist with symptom management. Sometimes a little more knowledge on our side means that we’re offering better information to the nurses, you know, quality information to the nurses. Instead of trying to describe something generally, we are able to be very specific, and the nurse knew exactly what we were talking about.
Some participants also commented that CCRs provided opportunities for debriefing and reflection on residents who were dying or had died. They recognized that reflection was
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KEYPOINTS Wickson-Griffiths, A., Kaasalainen, S., Brazil, K., McAiney, C., Crawshaw, D., Turner, M., & Kelley, M.L. (2015). Comfort Care Rounds: A Staff Capacity-Building Initiative in LongTerm Care Homes. Journal of Gerontological Nursing, 41(1), 42-48.
1
Comfort Care Rounds (CCRs) are a strategy to enhance the capacity of long-term care home staff and volunteers to provide high-quality palliative and end-of-life care for residents and families.
2
CCRs are a forum for resident case-based palliative and end-oflife care education that provides reflection, discussion, and peer support opportunities.
3
In the pilot evaluation, participants identified key facilitators and barriers to CCRs implementation, as well as their perceived outcomes and recommendations for improvement.
not only therapeutic for staff members, but it could also serve the dual purpose of being educational. A palliative care volunteer stated: Well, I think it’s effective and when they talk about someone dying, I think that’s very, for everyone, especially if you have been with them a long time, I think that’s very positive for the staff, recognizing that they have grief and grieve as well for someone who is lost. Because usually they have been with that person, you know, for a long time and have had some sort of attachment: they are not totally impersonal. In fact, I find them very warm to the people there.
Participant Recommendations. Participants suggested several ideas for improving how CCRs are conducted. First, participants stated that it would be helpful for staff to identify their palliative care learning needs prior to the meeting, as opposed to solely addressing topics as they came up in CCRs discussions. They provided examples, such as reviewing the physical cues of dying and communication and counseling strategies for future topics of discussion. Second, staff also provided suggestions on how the logistics and format of the CCRs could be altered. Some licensed nursing staff at one site preferred an in-depth, case study approach to CCRs, which would
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primarily focus on pain management. These staff members believed they would benefit more from a solutionbased conversation than reflection and debriefing. In addition, some staff suggested that having smaller scale, ad hoc CCRs on the individual LTC home units that focused on an individual resident during the endof-life stages would be beneficial. Third, participants also recognized that it would be advantageous to increase staff attendance at CCRs. They believed this increase might be achieved by improving the advertisement methods and conducting CCRs over lunch breaks and on the individual LTC home units. Overall Impressions. Many of the participants who attended CCRs used positive descriptors, such as “beneficial,” “enlightening,” “useful,” and “informative” to summarize their overall impression and experience. However, some participants recognized that although CCRs have good intentions, the structure and format need to be altered to be effective in improving palliative care practices and outcomes in LTC homes.
DISCUSSION Even with its high prevalence, death is often not addressed with staff in LTC homes (Moss, Moss, Rubinstein, & Black, 2003). Regard-
less of their educational preparation or immersion in caring for dying residents, those who attended CCRs sought to enhance their palliative and end-of-life care knowledge and practice. The need to improve knowledge is not unique to the study sites, as other researchers have collectively found that LTC home staff identified palliative and end-of-life care approaches and principles, symptom management, communication, and role definition as areas for further learning (Ersek et al., 1999; Whittaker, Kernohan, Hasson, Howard, & McLaughlin, 2006). In addition, international authors have used the Palliative Care Quiz for Nursing (Ross, McDonald, & McGuinness, 1996) to conclude that LTC home staff have common misconceptions about palliative care and recognize it as a general knowledge gap (Brazil et al., 2012; Raudonis, Kyba, & Kinsey, 2002; Ronaldson, Hayes, Carey, & Aggar, 2008). Given the overall prevalence of residents who will die in LTC homes, placing greater emphasis on palliative and end-of-life care capacity building at training and practice levels is well supported in the literature and in this pilot evaluation study. The current pilot evaluation demonstrated that LTC home staff and volunteers have multiple needs including education, emotional debriefing, and interprofessional case conferencing for dying residents. Participants identified all of these aspects as benefits of CCRs. However, this pilot study also found that it is difficult to be “all things to all people”; some staff valued gaining the input and perspectives of the larger health care team and volunteers, whereas others believed the focus of the CCRs was too broad. As the sites reshape how CCRs are conducted and this approach is used by more LTC homes, ongoing evaluation to determine an appropriate interprofessional approach is warranted. It is recognized that LTC home staff, especially PSWs, form family-
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like bonds with residents, given the nature of the intimate care they provide (Anderson, 2008; Moss et al., 2003; Sims-Gould et al., 2010). Indeed, the literature has demonstrated that LTC home staff used family as a metaphor when describing their relationship with dying residents (Moss et al., 2003). However, despite their close relationships with residents, staff often do not receive adequate training on how to manage grief or are not provided support after resident deaths (Moss et al., 2003). Thus, as CCRs encouraged attendees to review and reflect on past resident deaths, staff were provided with an outlet for expressing their feelings and reconciling significant events within the group. Providing a supportive outlet is an important consideration, as it was found that nursing assistants (e.g., PSWs) valued collegial recognition, support, and dialogue in helping cope with ongoing resident deaths (Beck et al., 2012). Additional research evaluation will help determine any staff or resident outcomes resulting from focusing on grieving and learning from dying residents’ issues during CCRs.
IMPLEMENTATION RECOMMENDATIONS In addition to conducting outcomes-based research, the authors of the current article offer the following recommendations to practitioners and administrative personnel wishing to implement CCRs or similar initiatives in their LTC homes. CCRs Duration/Frequency The authors recommend—perhaps through a process of trial and error—determining the timing and frequency that will provide the right balance of (a) accommodating the time needed to address attendees’ learning and reflection needs, (b) recognizing their heavy work demands, and (c) encouraging attendance. For several years, Site 2 has found that having CCRs (evolved from Pain Rounds) for 1 hour every month
helps strike this balance. Since the evaluation period ended and CCRs continued at Site 1, staff found that 30 minutes was not enough time to adequately accomplish their agenda. They have since increased the time to 1 hour, but now meet every 2 months.
months at Site 1 and 18 months at Site 2, which may have affected participants’ recall. Overall, these limitations may have impeded the participants’ ability to detail all of the benefits of and facilitators and barriers to the implementation of CCRs.
Do Not Reinvent the Wheel If not already obligated through legislation, LTC homes often have committees dedicated to improving residents’ quality of life, palliative care, and pain management. To increase efficiency and consider resident situations holistically, the authors recommend expanding the scope of these existing committees to incorporate key components (e.g., interdisciplinary representation, supporting attendees’ education and reflection needs) of CCRs.
As more individuals are dying in LTC home settings, innovative strategies are needed to enhance staff and volunteers’ capacity to provide highquality palliative and end-of-life care. CCRs are a strategy for providing interprofessional staff and palliative care volunteers with an opportunity to engage in case-based discussions and reflection on dying or deceased residents, as well as receive palliative and end-of-life care education. Overall, the participants in this pilot study evaluation found CCRs to be beneficial to their palliative and endof-life care knowledge, practice, and confidence. However, they identified several barriers to CCRs implementation and provided recommendations to improve the strategy, all of which warrant ongoing evaluation.
Maintain Strong Leadership Involvement Both the short-term nature and lack of sustainability have been recognized as shortcomings in implementing palliative care initiatives (Abbey, Froggatt, Parker, & Abbey, 2006). The evaluation sites had two advantages: managers who consistently endorsed and attended CCRs and a palliative care consultant (and a CAPCE trained nurse in Site 2) who were constant promoters and facilitators of the meetings. To reinforce the sustainability of CCRs, the authors recommend identifying and engaging individuals in leadership roles who are passionate about palliative care and will serve as role models to encourage staff to attend meetings.
LIMITATIONS The perspectives of LTC home staff who had not participated in any CCRs were included. Although it was important to understand the reasons for their non-attendance and strategies to effectively promote CCRs, this group comprised 20% (n = 8) of the sample. In addition, CCRs had been conducted for 10
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CONCLUSION
REFERENCES Abbey, J., Froggatt, K.A., Parker, D., & Abbey, B. (2006). Palliative care in long-term care: A system in change. International Journal of Older People Nursing, 1, 53-63. doi:10.1111/j.1748-3743.2006.00010.x. Anderson, K.A. (2008). Grief experiences of CNAs: Relationships with burnout and turnover. Journal of Gerontological Nursing, 34(1), 42-49. Beck, I., Törnquist, A., Bröstrom, L., & Edberg, A.K. (2012). Having to focus on doing rather than being: Nurse assistants’ experience of palliative care in municipal residential care settings. International Journal of Nursing Studies, 49, 455-464. doi:10.1016/j.ijnurstu.2011.10.016. Brazil, K., Bédard, M., Kreuger, P., Taniguchi, A., Kelley, M.L., McAiney, C., & Justice, C. (2006). Barriers to providing palliative care in long term care. Canadian Family Physician, 52, 472-473. Brazil, K., Brink, P., Kaasalainen, S., Kelly, M.L., & McAiney, C. (2012). Knowledge and perceived competence among nurses caring for the dying in long-term care homes. International Journal of Palliative Nursing, 18, 77-83. Canadian Healthcare Association. (2009). Pol-
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icy brief: New directions for facility-based long term care. Retrieved from http://www. cha.ca/wp-content/uploads/2012/11/ CHA_LTC_9-22-09_eng.pdf Canadian Hospice Palliative Care Association. (2014). FAQs—What is palliative care? Retrieved from http://www.chpca. net/family-caregivers/faqs.aspx Canadian Hospice Palliative Care Association, & Quality End-of-Life Care Coalition of Canada. (2014). The way forward. Retrieved from http://www. hpcintegration.ca/about-us.aspx Canadian Institute for Health Information. (2011). Health care in Canada, 2011: A focus on seniors and aging. Retrieved from https://secure.cihi.ca/ free_products/HCIC_2011_seniors_ report_en.pdf Canadian Institute for Health Information. (2012). Continuing Care Reporting System (CCRS) quick stats tables 20112012. Ottawa, Canada: Author. Ersek, M., Kraybill, B.M., & Hansberry, J. (1999). Investigating the educational needs of licensed nursing staff and certified nursing assistants in nursing homes regarding end-of-life care. American Journal of Hospice & Palliative Care, 16, 573-582. Ersek, M., Kraybill, B.M., & Hansberry, J. (2000). Assessing the educational needs and concerns of nursing home staff regarding end-of-life care. Journal of Gerontological Nursing, 26(10), 16-26. Hsieh, H.F., & Shannon, S.E. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15, 1277-1288. Kaasalainen, S., Brazil, K., & Kelley, M.L. (2012). Building capacity in palliative care for personal support workers in long term care through experiential learning. International Journal of Older People Nursing. Advance online publication. doi:10.1111/opn.12008 Landau, L., Brazil, K., Kaasalainen, S., & Crawshaw, D. (2013). Training and sustaining: A model for volunteer spiritual care visitors in long-term care. Journal of Religion, Spirituality & Aging, 25, 216237. doi:10.1080/15528030.2012.741562 Larocque, N., Schotsman, C., Kaasalainen, S., Crawshaw, D., McAiney, C., & Brazil, E. (2014). Using a book chat to influence attitudes and perceptions of longterm care staff about dementia. Journal of Gerontological Nursing, 40(5), 46-52.
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doi:10.3928/00989134-20140110-02 Moss, M.S., Moss, S.Z., Rubinstein, R.L., & Black, H.K. (2003). The metaphor of “family” in staff communication about dying and death. Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 58, S290-S296. Palliative Alliance. (2014). Quality palliative care in long term care: A communityuniversity research alliance. Retrieved from http://www.palliativealliance.ca Powers, B.A., & Watson, N.M. (2008). Meaning and practice of palliative care for nursing home residents with dementia at end of life. American Journal of Alzheimer’s Disease & Other Dementias, 23, 319325. doi:10.1177/1533317508316682 Raudonis, B.M., Kyba, F.C., & Kinsey, T.A. (2002). Long-term care nurses’ knowledge of end-of-life care. Geriatric Nursing, 23, 296-301. Ronaldson, S., Hayes, L., Carey, M., & Aggar, C. (2008). A study of nurses’ knowledge of a palliative approach in residential aged care facilities. International Journal of Older People Nursing, 3, 258-267. doi:10.1111/j.17483743.2008.00136.x Ross, M.M., McDonald, B., & McGuinness, J. (1996). The palliative care quiz for nursing (PCQN): The development of an instrument to measure nurses’ knowledge of palliative care. Journal of Advanced Nursing, 23, 126-137. Sandelowski, M. (2000). Whatever happened to qualitative description? Research in Nursing & Health, 23, 334-340. Sims-Gould, J., Wiersma, E., Arseneau, L., Kelley, M.L., Kozak, J., Habjan, S., & MacLean, M. (2010). Care provider perspectives on end-of-life care in long-term-care homes: Implications for whole-person and palliative care. Journal of Palliative Care, 26, 122-129. Whittaker, E., Kernohan, W.G., Hasson, F., Howard, V., & McLaughlin, D. (2006). The palliative care education needs of nursing home staff. Nurse Education Today, 26, 501-510. World Health Organization. (2014). WHO definition of palliative care. Retrieved from http://www.who.int/cancer/ palliative/definition/en ABOUT THE AUTHORS
Ms. Wickson-Griffiths is Technology Evaluation in the Elderly Network
(TVN) Interdisciplinary Fellow, and Dr. Kaasalainen is Associate Professor, School of Nursing, McMaster University, Hamilton, Ontario, Canada; Dr. Brazil is Professor, Palliative Care, School of Nursing and Midwifery, Queen’s University Belfast, Belfast, United Kingdom; Dr. McAiney is Associate Professor, Department of Psychiatry and Behavioural Neurosciences, McMaster University, and Director of Evaluation and Research, Seniors Mental Health Services, St. Joseph’s Healthcare, Hamilton, Ontario, Canada; Ms. Crawshaw is Research Coordinator, McMaster University, Hamilton, Ontario, Canada; Ms. Turner is Palliative Care Consultant, Acclaim Health, Oakville, Ontario, Canada; and Dr. Kelley is Professor of Social Work and Gerontology, School of Social Work, Lakehead University, Thunder Bay, Ontario, Canada. The authors have disclosed no potential conflicts of interest, financial or otherwise. This research was supported by the Social Sciences and Humanities Research Council (SSHRC) and Canadian Institutes of Health Research (CIHR) [CIHR FRN: 112484]. Ms. Wickson-Griffiths is an Interdisciplinary Fellow funded by TVN, which is supported by the Government of Canada through the Networks of Centres of Excellence program. She was a previous recipient of the D’Souza Scholarship and a student trainee funded by SSHRC and CIHR through the Improving the Quality of Life for People Dying in Long-Term Care Homes study. The authors acknowledge the student trainee research assistance from Rachel Schofield and Heather Gale. They also thank all of the participants involved in the Comfort Care Rounds evaluation interviews and focus groups. Address correspondence to Sharon Kaasalainen, PhD, RN, Associate Professor, School of Nursing, McMaster University, Health Sciences Centre 3N25F, 1280 Main Street West, Hamilton, Ontario, Canada L8S 4K1; e-mail: [email protected]. Received: January 30, 2014 Accepted: May 21, 2014 Posted: June 18, 2014 doi:10.3928/00989134-20140611-01
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Appendix A- Detailed Description of Comfort Care Rounds Purpose: To provide a forum for staff and volunteer education, discussion, and reflection on resident cases of palliative and end-of-life care Schedule: ½ -1 hour on a monthly basis Attendees: All members of the interprofessional team and palliative care volunteers are welcome Roles/Responsibilities: 1) Develop a Comfort Care Rounds (CCRs) agenda 2) Advertise and promote to staff and volunteers 3) Facilitate or chair CCRs discussion a. Review list of resident deaths b. Case-based discussion/reflection on resident deaths or those dying c. Case study approach to discussion on resident palliative care issues 4) Provide formal/informal palliative care education 5) Disseminate minutes/proceedings to those who could not attend Structure: Depending on the needs of the attendees, the CCRs can be structured to include several components. Key components include: 1) Introducing New Attendees–Given the interprofessional approach and inclusion of palliative care volunteers, CCRs attendees should introduce themselves. 2) Review of Resident Deaths–Prior to the CCRs, compile and distribute a list of residents who have died or who are nearing end-of-life since the last meeting. 3) Reflect and Debrief on Resident Deaths–Provide time for attendees to reflect and discuss recent resident deaths. They may wish to reflect on or debrief about successes, areas for improvement, and general feelings about their palliative and end-of-life care experiences. 4) Case-based Discussion and Planning–Dedicate time to a specific (current/past) resident and/or family case. Attendees may prepare a case presentation prior to the CCRs with specific points for group discussion. The goal of the case-based discussion and planning may be to present issues and discuss solutions, debrief or provide education. 5) Educational Component–Give time for the CCRs facilitator, palliative care leader, or other attendees to provide more formal education about a palliative care topic or issue. Topics or issues may be predetermined or arise during the CCRs.
A Staff Capacity-Building Initiative in Long-Term Care Homes ABSTRACT This article reports a pilot evaluation of Comfort Care Rounds
difficulty in balancing heavy workloads and scheduling logis-
(CCRs)—a strategy for addressing long-term care home staff ’s
tics. Interprofessional team member representation was sought
palliative and end-of-life care educational and support needs.
but was not consistent. Study participants recognized the ben-
Using a qualitative descriptive design, semistructured individual
efits of attending; however, they provided feedback on how the
and focus group interviews were conducted to understand staff
scheduling, content, and focus could be improved. Overall, study
members’ perspectives and feedback on the implementation and
participants found CCRs to be beneficial to their palliative and
application of CCRs. Study participants identified that effective
end-of-life care knowledge, practice, and confidence. However,
advertising, interest, and assigning staff to attend CCRs facilitated
they identified barriers and recommendations, which warrant on-
their participation. The key barriers to their attendance included
going evaluation. [Journal of Gerontological Nursing, 40(1), 42-48.]
Abigail Wickson-Griffiths, RN, MN; Sharon Kaasalainen, PhD, RN; Kevin Brazil, PhD; Carrie McAiney, PhD; Diane Crawshaw, BA; Mickey Turner, RN, CHPCN(C); and Mary Lou Kelley, PhD, MSW 42
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A
pproximately 44% of residents die in Canadian longterm care (LTC) home settings each year (Canadian Institute for Health Information [CIHI], 2012); therefore, the need to provide high-quality palliative and end-oflife care is warranted. The World Health Organization (WHO; 2014) explains that palliative care is a holistic approach to improving the quality of life for patients who have a life-threatening illness and their family members, through preventing and relieving the patient’s suffering. Ensuring access to quality palliative and end-of-life care is a priority in Canada, as seen through initiatives such as The Way Forward (Canadian Hospice Palliative Care Association [CHPCA] & Quality End-of-Life Care Coalition of Canada, 2014). Given residents’ advanced age, care needs, and desire to remain in their LTC homes until death, these facilities must strategize to ensure delivery of high-quality palliative care (Brazil et al., 2006; Canadian Healthcare Association, 2009; CIHI, 2011). However, studies focusing on LTC home staff’s knowledge regarding the care of dying residents and their families demonstrate an area for growth (Brazil, Brink, Kaasalainen, Kelly, & McAiney, 2012; Ersek, Kraybill, & Hansberry, 1999, 2000). In addition to building knowledge, providing LTC home staff with opportunities for support and reflection on deceased residents must also be addressed (Beck, Törnquist, Bröstrom, & Edberg, 2012). Comfort Care Rounds (CCRs), practiced at two Canadian LTC homes, are a strategy for addressing staff’s palliative and end-of-life care educational and support needs.
CONTEXT Since 2009, four LTC homes have partnered with two Canadian universities to engage in the Improving the Quality of Life for People Dying
in Long-Term Care Homes study (Palliative Alliance, 2014). The study uses a participatory action research approach, by which university researchers work in partnership with the LTC homes, as well as community and national partners, to help improve palliative care approaches, processes, and delivery. A key goal of the study is to educate and empower unlicensed care providers, also called personal support workers (PSWs), to improve the quality of palliative care for LTC home residents and their family members. Other strategies evaluated in this study that focused on improving the quality of life and care for dying residents have been reported previously (Kaasalainen, Brazil, & Kelley, 2012; Landau, Brazil, Kaasalainen, & Crawshaw, 2013; Larocque et al., 2014). The current article reports the pilot evaluation of the CCRs strategy, practiced at two LTC homes in southwestern Ontario, Canada (hereafter referred to as Site 1 and Site 2).
DESCRIPTION OF CCRs In Site 2, CCRs evolved from Pain Rounds, which were attended by licensed nursing staff to share information about resident pain management. As the licensed nursing staff became more knowledgeable, their attendance at the Pain Rounds declined. To attract staff attendance and address their broader interest in palliative care delivery, the Pain Rounds evolved into CCRs. The regional palliative care consultant and a comprehensive advanced palliative care education (CAPCE) trained nurse were responsible for transitioning the Pain Rounds to the CCRs strategy. Approximately 8 months later, the palliative care consultant implemented CCRs at Site 1. During the evaluation period, CCRs were scheduled on a monthly basis, for 30 minutes at Site 1 and 1 hour at Site 2. All members of the interprofessional team and palliative care volunteers were welcomed to attend.
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The home-wide attendees gathered in a central meeting room to discuss resident case-based palliative and end-of-life care issues. Of note, palliative care is recognized by CCRs chairs as a holistic approach to care, which promotes comfort and dignity for individuals with life-limiting illness(es) and their family members (CHPCA, 2014). During CCRs, end-of-life care is usually discussed in the context of the care provided when the resident is actively dying; however, no definite time period for when end-of-life care occurs has been determined in the literature (Powers & Watson, 2008). At Sites 1 and 2, the goal of CCRs is to provide an LTC home-wide forum for staff and palliative care volunteers to engage in case-based discussions about palliative and endof-life care for deceased or dying residents. To meet this goal, the palliative care consultant, CAPCE-trained nurse, and other CCRs leaders (e.g., nurse managers) are responsible for chairing or co-chairing CCRs with interprofessional staff and palliative care volunteers. The CCRs chairs have several roles and responsibilities, including developing an agenda, promoting and advertising CCRs, facilitating discussion, providing education, and disseminating key messages to staff not in attendance. The chairs focus is on providing palliative and end-of-life care education; debriefing opportunities, reflection, and discussion on resident cases; and peer support for staff and volunteers. However, CCRs are intended to meet the learning and reflection needs of the staff and volunteers and are therefore flexible in terms of the content reflected on and discussed. For a summary of the strategy, see Appendix A (available in the online version of this article). In a typical CCRs meeting, the chair will start by reviewing recent resident deaths and then ask and respond to a series of questions to help identify attendees’ learning and
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reflection needs. Examples of questions include: ● What aspects of the end-of-life or after care went well or did not? ● What are the possible reasons this situation went well or did not, and what can be done differently next time? ● How did this end-of-life care experience make you feel? Depending on the topic areas that the attendees respond with, the CCRs chair will then provide educational (i.e., correct misconceptions about or offer optimal care processes, discuss strategies to promote resident and family comfort) and emotional (i.e., affirm attendees’ practices and processes, acknowledge emotions and experiences) support.
METHOD Using a qualitative descriptive design described by Sandelowski (2000), the research team sought to evaluate the implementation, format, process, and outcomes of CCRs. At the time of the pilot evaluation, CCRs were held for approximately 10 months at Site 1 and 18 months at Site 2. With guidance, two research assistants conducted semistructured focus groups and individual interviews with staff and a volunteer from both sites to learn their perspectives. Poster advertisements and wordof-mouth from staff were two strategies used to recruit focus group participants. To gain a variety of perspectives, staff were encouraged to attend the focus groups regardless of their level of participation at the CCRs. Two focus groups were conducted with licensed nurses (n = 18) and three with PSWs (n = 12). In addition, 10 individual interviews were conducted with members of the interprofessional staff and administration, as well as a palliative care volunteer. The interview participants either actively attended CCRs or were involved with its implementation or monthly organization. Prior to the pilot evaluation, an ethics review and approval was ob-
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tained at the university and community levels. Written consent was obtained from all participants. All participants were asked to provide feedback about their CCRs experiences. They were asked about the facilitators and barriers to the implementation, outcomes, and ways to improve CCRs (the interview guide is available upon request from the authors). The focus groups and interviews took between 10 and 45 minutes to complete. The variation in length related to the number of participants and their level of involvement in CCRs. In recognition of their time, participants received a $15 gift card. With permission, the focus group and individual interview discussions were audiorecorded and transcribed. Thematic content analysis was used to interpret the findings (Hsieh & Shannon, 2005). All transcripts were read in their entirety to gain a sense of the entire dataset. Eight of the 10 individual interview transcripts were independently coded by two individuals (A.W.-G., S.K.) to establish a master coding list. Discrepancies were discussed until consensus on a coding framework was reached. One individual (A.W.-G.) coded all transcripts according to the coding framework. Once all of the data were coded, overarching themes that emerged were identified by two individuals (A.W.-G., S.K.).
RESULTS Participants Forty participants took part in the CCRs evaluation. Participants were requested to complete a demographics questionnaire; 39 questionnaires were returned. The majority of participants were women (97.5%) employed as either a licensed nurse (45%) or PSW (35%) with at least 5 years of LTC home work experience (84.6%). Most participants indicated having previous palliative care education (88.8%). Participants also reported having attended on average three
(SD = 3.3) CCRs; however, eight participants had not attended any CCRs. Overview of Findings The analysis of the focus group and individual interview discussions identified several themes, including: facilitators and barriers to implementation and application, the interprofessional approach, perceived outcomes, recommendations for improvement, and overall impressions of CCRs. The main themes are described below. Factors That Facilitate CCRs. Participants suggested several facilitator strategies that helped implement and sustain CCRs, including effective advertising and promotion, management support, and staff interest. At both sites, a combination of methods was used to advertise and encourage staff attendance, including a notice in the education calendar, e-mail reminders, memos, posters in the nursing station, and personal encouragement to attend. In addition, to specifically promote PSW attendance at Site 1, a licensed nursing staff member assigned one PSW to attend CCRs and instructed the staff remaining on the resident unit to cover the work of that individual. Staff identified that managers were often in attendance and personally reminded others to attend CCRs. Staff interest in palliative care was also a key facilitator in promoting attendance at CCRs. Barriers to CCRs. Barriers to planning and implementing CCRs were also identified and included balancing competing demands and resident-care workload, a lack of unit coverage, scheduling difficulties, and lack of awareness and interest in CCRs. Staff recognized that they had to balance competing work demands on the units with attending CCRs. In addition, both sites provided other educational opportunities and in-services, which also needed to be prioritized by staff. A licensed nurse stated:
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It’s trying to get everything accomplished. So that makes it difficult because you are pulled, like, you want to know and you would be a better nurse for it, but you still have the demands that pull you away from the learning.
Participants also voiced concerns that they were not always replaced with other staff when they attended CCRs, leaving remaining staff on the resident unit to manage heavy workloads. Not only did this limit the number of staff who could attend per unit (usually either one licensed nurse or PSW), but it also left staff feeling as though they needed to “catch up” with work on their return. In addition, although effort was put into scheduling CCRs at both sites, challenges were still identified with the selected dates and times. Finally, although the sites used a variety of methods to advertise CCRs and encourage attendance, some staff lacked awareness or were not interested in attending. Interprofessional Approach to CCRs. Increasing interprofessional attendance, especially for PSWs, was a mutual goal of the LTC home sites and the research team. However, neither site had consistent interprofessional team attendance. Despite this lack of attendance, some participants recognized the role that all team members can play in providing palliative care. A palliative care volunteer stated, “I think it’s very valuable. I think it’s valuable to everyone. It’s a continuum of care, not just departmentalized.” In addition, staff at one site believed that an open and safe environment was created for all attendees to share their experiences. It was expected that by encouraging the interprofessional team to attend, they would learn more about each others’ roles in providing palliative and end-of-life care. However, challenges were identified in the interprofessional approach to CCRs. Some staff at one site believed they were losing the depth of nursing-focused discussion by
including other disciplines. In fact, participants at both sites recognized that their discussions had to be more broadly focused to be inclusive of all attendees. Overall, it was difficult to find a discussion focus that would meet everyone’s learning needs. In addition, given that resident care was their first priority, by encouraging PSWs to attend, the licensed nursing staff could not attend and vice versa. It proved difficult to find a time that worked for the majority to attend and achieve interprofessional representation. Perceived Outcomes. When asked about the benefits or outcomes of at-
Improved communication or working relationships among staff members and volunteers was another noted outcome. For example, a participant spoke about how individuals gathered discipline-specific information about residents; however, it was not always well communicated to other staff members. Thus, CCRs provided an opportunity for the interprofessional team to share their unique perspectives on the residents, ultimately improving team communication and knowledge about the residents. PSW empowerment in providing palliative care was another outcome.
Comfort Care Rounds provided an opportunity for the interprofessional team to share their unique perspectives on the residents, ultimately improving team communication and knowledge about the residents.
tending CCRs, participants offered a variety of responses regarding new knowledge, improved confidence and communication, staff empowerment, and chances for debriefing and reflection. Although some participants could not identify any outcomes or changes in practice as a result of participating in CCRs, other participants talked about either refreshing or gaining new knowledge on palliative or end-of-life care approaches. Participants provided examples of learning about physical care during end-of-life, such as oxygen therapy and suctioning; social interventions, such as music therapy and addressing spirituality; and general knowledge about palliative and end-of-life care. Along with new knowledge, some participants also reported an increased confidence in providing palliative and end-of-life care to residents and families.
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Along with increased confidence, a PSW explained that by attending CCRs, she learned how PSWs can be more involved in providing palliative care. She also noted that licensed nursing staff had a greater awareness of the potential of the PSW role: It gave us an opportunity to find out what we could do at the PSW level to help assist with symptom management. Sometimes a little more knowledge on our side means that we’re offering better information to the nurses, you know, quality information to the nurses. Instead of trying to describe something generally, we are able to be very specific, and the nurse knew exactly what we were talking about.
Some participants also commented that CCRs provided opportunities for debriefing and reflection on residents who were dying or had died. They recognized that reflection was
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KEYPOINTS Wickson-Griffiths, A., Kaasalainen, S., Brazil, K., McAiney, C., Crawshaw, D., Turner, M., & Kelley, M.L. (2015). Comfort Care Rounds: A Staff Capacity-Building Initiative in LongTerm Care Homes. Journal of Gerontological Nursing, 41(1), 42-48.
1
Comfort Care Rounds (CCRs) are a strategy to enhance the capacity of long-term care home staff and volunteers to provide high-quality palliative and end-of-life care for residents and families.
2
CCRs are a forum for resident case-based palliative and end-oflife care education that provides reflection, discussion, and peer support opportunities.
3
In the pilot evaluation, participants identified key facilitators and barriers to CCRs implementation, as well as their perceived outcomes and recommendations for improvement.
not only therapeutic for staff members, but it could also serve the dual purpose of being educational. A palliative care volunteer stated: Well, I think it’s effective and when they talk about someone dying, I think that’s very, for everyone, especially if you have been with them a long time, I think that’s very positive for the staff, recognizing that they have grief and grieve as well for someone who is lost. Because usually they have been with that person, you know, for a long time and have had some sort of attachment: they are not totally impersonal. In fact, I find them very warm to the people there.
Participant Recommendations. Participants suggested several ideas for improving how CCRs are conducted. First, participants stated that it would be helpful for staff to identify their palliative care learning needs prior to the meeting, as opposed to solely addressing topics as they came up in CCRs discussions. They provided examples, such as reviewing the physical cues of dying and communication and counseling strategies for future topics of discussion. Second, staff also provided suggestions on how the logistics and format of the CCRs could be altered. Some licensed nursing staff at one site preferred an in-depth, case study approach to CCRs, which would
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primarily focus on pain management. These staff members believed they would benefit more from a solutionbased conversation than reflection and debriefing. In addition, some staff suggested that having smaller scale, ad hoc CCRs on the individual LTC home units that focused on an individual resident during the endof-life stages would be beneficial. Third, participants also recognized that it would be advantageous to increase staff attendance at CCRs. They believed this increase might be achieved by improving the advertisement methods and conducting CCRs over lunch breaks and on the individual LTC home units. Overall Impressions. Many of the participants who attended CCRs used positive descriptors, such as “beneficial,” “enlightening,” “useful,” and “informative” to summarize their overall impression and experience. However, some participants recognized that although CCRs have good intentions, the structure and format need to be altered to be effective in improving palliative care practices and outcomes in LTC homes.
DISCUSSION Even with its high prevalence, death is often not addressed with staff in LTC homes (Moss, Moss, Rubinstein, & Black, 2003). Regard-
less of their educational preparation or immersion in caring for dying residents, those who attended CCRs sought to enhance their palliative and end-of-life care knowledge and practice. The need to improve knowledge is not unique to the study sites, as other researchers have collectively found that LTC home staff identified palliative and end-of-life care approaches and principles, symptom management, communication, and role definition as areas for further learning (Ersek et al., 1999; Whittaker, Kernohan, Hasson, Howard, & McLaughlin, 2006). In addition, international authors have used the Palliative Care Quiz for Nursing (Ross, McDonald, & McGuinness, 1996) to conclude that LTC home staff have common misconceptions about palliative care and recognize it as a general knowledge gap (Brazil et al., 2012; Raudonis, Kyba, & Kinsey, 2002; Ronaldson, Hayes, Carey, & Aggar, 2008). Given the overall prevalence of residents who will die in LTC homes, placing greater emphasis on palliative and end-of-life care capacity building at training and practice levels is well supported in the literature and in this pilot evaluation study. The current pilot evaluation demonstrated that LTC home staff and volunteers have multiple needs including education, emotional debriefing, and interprofessional case conferencing for dying residents. Participants identified all of these aspects as benefits of CCRs. However, this pilot study also found that it is difficult to be “all things to all people”; some staff valued gaining the input and perspectives of the larger health care team and volunteers, whereas others believed the focus of the CCRs was too broad. As the sites reshape how CCRs are conducted and this approach is used by more LTC homes, ongoing evaluation to determine an appropriate interprofessional approach is warranted. It is recognized that LTC home staff, especially PSWs, form family-
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like bonds with residents, given the nature of the intimate care they provide (Anderson, 2008; Moss et al., 2003; Sims-Gould et al., 2010). Indeed, the literature has demonstrated that LTC home staff used family as a metaphor when describing their relationship with dying residents (Moss et al., 2003). However, despite their close relationships with residents, staff often do not receive adequate training on how to manage grief or are not provided support after resident deaths (Moss et al., 2003). Thus, as CCRs encouraged attendees to review and reflect on past resident deaths, staff were provided with an outlet for expressing their feelings and reconciling significant events within the group. Providing a supportive outlet is an important consideration, as it was found that nursing assistants (e.g., PSWs) valued collegial recognition, support, and dialogue in helping cope with ongoing resident deaths (Beck et al., 2012). Additional research evaluation will help determine any staff or resident outcomes resulting from focusing on grieving and learning from dying residents’ issues during CCRs.
IMPLEMENTATION RECOMMENDATIONS In addition to conducting outcomes-based research, the authors of the current article offer the following recommendations to practitioners and administrative personnel wishing to implement CCRs or similar initiatives in their LTC homes. CCRs Duration/Frequency The authors recommend—perhaps through a process of trial and error—determining the timing and frequency that will provide the right balance of (a) accommodating the time needed to address attendees’ learning and reflection needs, (b) recognizing their heavy work demands, and (c) encouraging attendance. For several years, Site 2 has found that having CCRs (evolved from Pain Rounds) for 1 hour every month
helps strike this balance. Since the evaluation period ended and CCRs continued at Site 1, staff found that 30 minutes was not enough time to adequately accomplish their agenda. They have since increased the time to 1 hour, but now meet every 2 months.
months at Site 1 and 18 months at Site 2, which may have affected participants’ recall. Overall, these limitations may have impeded the participants’ ability to detail all of the benefits of and facilitators and barriers to the implementation of CCRs.
Do Not Reinvent the Wheel If not already obligated through legislation, LTC homes often have committees dedicated to improving residents’ quality of life, palliative care, and pain management. To increase efficiency and consider resident situations holistically, the authors recommend expanding the scope of these existing committees to incorporate key components (e.g., interdisciplinary representation, supporting attendees’ education and reflection needs) of CCRs.
As more individuals are dying in LTC home settings, innovative strategies are needed to enhance staff and volunteers’ capacity to provide highquality palliative and end-of-life care. CCRs are a strategy for providing interprofessional staff and palliative care volunteers with an opportunity to engage in case-based discussions and reflection on dying or deceased residents, as well as receive palliative and end-of-life care education. Overall, the participants in this pilot study evaluation found CCRs to be beneficial to their palliative and endof-life care knowledge, practice, and confidence. However, they identified several barriers to CCRs implementation and provided recommendations to improve the strategy, all of which warrant ongoing evaluation.
Maintain Strong Leadership Involvement Both the short-term nature and lack of sustainability have been recognized as shortcomings in implementing palliative care initiatives (Abbey, Froggatt, Parker, & Abbey, 2006). The evaluation sites had two advantages: managers who consistently endorsed and attended CCRs and a palliative care consultant (and a CAPCE trained nurse in Site 2) who were constant promoters and facilitators of the meetings. To reinforce the sustainability of CCRs, the authors recommend identifying and engaging individuals in leadership roles who are passionate about palliative care and will serve as role models to encourage staff to attend meetings.
LIMITATIONS The perspectives of LTC home staff who had not participated in any CCRs were included. Although it was important to understand the reasons for their non-attendance and strategies to effectively promote CCRs, this group comprised 20% (n = 8) of the sample. In addition, CCRs had been conducted for 10
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CONCLUSION
REFERENCES Abbey, J., Froggatt, K.A., Parker, D., & Abbey, B. (2006). Palliative care in long-term care: A system in change. International Journal of Older People Nursing, 1, 53-63. doi:10.1111/j.1748-3743.2006.00010.x. Anderson, K.A. (2008). Grief experiences of CNAs: Relationships with burnout and turnover. Journal of Gerontological Nursing, 34(1), 42-49. Beck, I., Törnquist, A., Bröstrom, L., & Edberg, A.K. (2012). Having to focus on doing rather than being: Nurse assistants’ experience of palliative care in municipal residential care settings. International Journal of Nursing Studies, 49, 455-464. doi:10.1016/j.ijnurstu.2011.10.016. Brazil, K., Bédard, M., Kreuger, P., Taniguchi, A., Kelley, M.L., McAiney, C., & Justice, C. (2006). Barriers to providing palliative care in long term care. Canadian Family Physician, 52, 472-473. Brazil, K., Brink, P., Kaasalainen, S., Kelly, M.L., & McAiney, C. (2012). Knowledge and perceived competence among nurses caring for the dying in long-term care homes. International Journal of Palliative Nursing, 18, 77-83. Canadian Healthcare Association. (2009). Pol-
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icy brief: New directions for facility-based long term care. Retrieved from http://www. cha.ca/wp-content/uploads/2012/11/ CHA_LTC_9-22-09_eng.pdf Canadian Hospice Palliative Care Association. (2014). FAQs—What is palliative care? Retrieved from http://www.chpca. net/family-caregivers/faqs.aspx Canadian Hospice Palliative Care Association, & Quality End-of-Life Care Coalition of Canada. (2014). The way forward. Retrieved from http://www. hpcintegration.ca/about-us.aspx Canadian Institute for Health Information. (2011). Health care in Canada, 2011: A focus on seniors and aging. Retrieved from https://secure.cihi.ca/ free_products/HCIC_2011_seniors_ report_en.pdf Canadian Institute for Health Information. (2012). Continuing Care Reporting System (CCRS) quick stats tables 20112012. Ottawa, Canada: Author. Ersek, M., Kraybill, B.M., & Hansberry, J. (1999). Investigating the educational needs of licensed nursing staff and certified nursing assistants in nursing homes regarding end-of-life care. American Journal of Hospice & Palliative Care, 16, 573-582. Ersek, M., Kraybill, B.M., & Hansberry, J. (2000). Assessing the educational needs and concerns of nursing home staff regarding end-of-life care. Journal of Gerontological Nursing, 26(10), 16-26. Hsieh, H.F., & Shannon, S.E. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15, 1277-1288. Kaasalainen, S., Brazil, K., & Kelley, M.L. (2012). Building capacity in palliative care for personal support workers in long term care through experiential learning. International Journal of Older People Nursing. Advance online publication. doi:10.1111/opn.12008 Landau, L., Brazil, K., Kaasalainen, S., & Crawshaw, D. (2013). Training and sustaining: A model for volunteer spiritual care visitors in long-term care. Journal of Religion, Spirituality & Aging, 25, 216237. doi:10.1080/15528030.2012.741562 Larocque, N., Schotsman, C., Kaasalainen, S., Crawshaw, D., McAiney, C., & Brazil, E. (2014). Using a book chat to influence attitudes and perceptions of longterm care staff about dementia. Journal of Gerontological Nursing, 40(5), 46-52.
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doi:10.3928/00989134-20140110-02 Moss, M.S., Moss, S.Z., Rubinstein, R.L., & Black, H.K. (2003). The metaphor of “family” in staff communication about dying and death. Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 58, S290-S296. Palliative Alliance. (2014). Quality palliative care in long term care: A communityuniversity research alliance. Retrieved from http://www.palliativealliance.ca Powers, B.A., & Watson, N.M. (2008). Meaning and practice of palliative care for nursing home residents with dementia at end of life. American Journal of Alzheimer’s Disease & Other Dementias, 23, 319325. doi:10.1177/1533317508316682 Raudonis, B.M., Kyba, F.C., & Kinsey, T.A. (2002). Long-term care nurses’ knowledge of end-of-life care. Geriatric Nursing, 23, 296-301. Ronaldson, S., Hayes, L., Carey, M., & Aggar, C. (2008). A study of nurses’ knowledge of a palliative approach in residential aged care facilities. International Journal of Older People Nursing, 3, 258-267. doi:10.1111/j.17483743.2008.00136.x Ross, M.M., McDonald, B., & McGuinness, J. (1996). The palliative care quiz for nursing (PCQN): The development of an instrument to measure nurses’ knowledge of palliative care. Journal of Advanced Nursing, 23, 126-137. Sandelowski, M. (2000). Whatever happened to qualitative description? Research in Nursing & Health, 23, 334-340. Sims-Gould, J., Wiersma, E., Arseneau, L., Kelley, M.L., Kozak, J., Habjan, S., & MacLean, M. (2010). Care provider perspectives on end-of-life care in long-term-care homes: Implications for whole-person and palliative care. Journal of Palliative Care, 26, 122-129. Whittaker, E., Kernohan, W.G., Hasson, F., Howard, V., & McLaughlin, D. (2006). The palliative care education needs of nursing home staff. Nurse Education Today, 26, 501-510. World Health Organization. (2014). WHO definition of palliative care. Retrieved from http://www.who.int/cancer/ palliative/definition/en ABOUT THE AUTHORS
Ms. Wickson-Griffiths is Technology Evaluation in the Elderly Network
(TVN) Interdisciplinary Fellow, and Dr. Kaasalainen is Associate Professor, School of Nursing, McMaster University, Hamilton, Ontario, Canada; Dr. Brazil is Professor, Palliative Care, School of Nursing and Midwifery, Queen’s University Belfast, Belfast, United Kingdom; Dr. McAiney is Associate Professor, Department of Psychiatry and Behavioural Neurosciences, McMaster University, and Director of Evaluation and Research, Seniors Mental Health Services, St. Joseph’s Healthcare, Hamilton, Ontario, Canada; Ms. Crawshaw is Research Coordinator, McMaster University, Hamilton, Ontario, Canada; Ms. Turner is Palliative Care Consultant, Acclaim Health, Oakville, Ontario, Canada; and Dr. Kelley is Professor of Social Work and Gerontology, School of Social Work, Lakehead University, Thunder Bay, Ontario, Canada. The authors have disclosed no potential conflicts of interest, financial or otherwise. This research was supported by the Social Sciences and Humanities Research Council (SSHRC) and Canadian Institutes of Health Research (CIHR) [CIHR FRN: 112484]. Ms. Wickson-Griffiths is an Interdisciplinary Fellow funded by TVN, which is supported by the Government of Canada through the Networks of Centres of Excellence program. She was a previous recipient of the D’Souza Scholarship and a student trainee funded by SSHRC and CIHR through the Improving the Quality of Life for People Dying in Long-Term Care Homes study. The authors acknowledge the student trainee research assistance from Rachel Schofield and Heather Gale. They also thank all of the participants involved in the Comfort Care Rounds evaluation interviews and focus groups. Address correspondence to Sharon Kaasalainen, PhD, RN, Associate Professor, School of Nursing, McMaster University, Health Sciences Centre 3N25F, 1280 Main Street West, Hamilton, Ontario, Canada L8S 4K1; e-mail: [email protected]. Received: January 30, 2014 Accepted: May 21, 2014 Posted: June 18, 2014 doi:10.3928/00989134-20140611-01
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Appendix A- Detailed Description of Comfort Care Rounds Purpose: To provide a forum for staff and volunteer education, discussion, and reflection on resident cases of palliative and end-of-life care Schedule: ½ -1 hour on a monthly basis Attendees: All members of the interprofessional team and palliative care volunteers are welcome Roles/Responsibilities: 1) Develop a Comfort Care Rounds (CCRs) agenda 2) Advertise and promote to staff and volunteers 3) Facilitate or chair CCRs discussion a. Review list of resident deaths b. Case-based discussion/reflection on resident deaths or those dying c. Case study approach to discussion on resident palliative care issues 4) Provide formal/informal palliative care education 5) Disseminate minutes/proceedings to those who could not attend Structure: Depending on the needs of the attendees, the CCRs can be structured to include several components. Key components include: 1) Introducing New Attendees–Given the interprofessional approach and inclusion of palliative care volunteers, CCRs attendees should introduce themselves. 2) Review of Resident Deaths–Prior to the CCRs, compile and distribute a list of residents who have died or who are nearing end-of-life since the last meeting. 3) Reflect and Debrief on Resident Deaths–Provide time for attendees to reflect and discuss recent resident deaths. They may wish to reflect on or debrief about successes, areas for improvement, and general feelings about their palliative and end-of-life care experiences. 4) Case-based Discussion and Planning–Dedicate time to a specific (current/past) resident and/or family case. Attendees may prepare a case presentation prior to the CCRs with specific points for group discussion. The goal of the case-based discussion and planning may be to present issues and discuss solutions, debrief or provide education. 5) Educational Component–Give time for the CCRs facilitator, palliative care leader, or other attendees to provide more formal education about a palliative care topic or issue. Topics or issues may be predetermined or arise during the CCRs.
