rinance and management
Developing standards in palliative care
w
Lesley Marsh, Guy’s Hospital, London
Palliative care for cancer patients has improved dramatically in recent years. Such care also benefits patients dying from chronic illnesses. This article explains how nursing standards were written for patients with cancer and acute and chronic illnesses requiring palliative care. Miss Marsh is a Staff Nurse at Guy’s Hospital, St Thomas Street, London SEl 9RT
W W hilc undertaking the 3-month palliative care course at the Nightingale and Guy’s College of Health earlier this year, I was challenged by the course tutor to im prove an area of palliative care within the acute assessment and rehabilitation elderly care ward where I work (Addison ward), as many of the patients are in hospital for long periods and many receive palliative care. Although we did not monitor the level of palliative care that we were delivering, we instinctively considered it to be of a high standard. However, we decided to create a philosophy and produce written stan dards of care to help us define the quality of care we could and should deliver. Schofield (1990) supports the view that setting explicit standards raises care to the highest level and allows every member of the ward team to know exactly what is ex pected of him/her. Standard setting ensures that nursing care is constantly evaluated and updated so that the practice of nursing moves towards excellence.
Background
After discussion with my ward sister, sen ior nurse and ward staff, I coordinated all of their ideas and began to draft the stan Table I. C hecklist to consult when selecting a topic fo r a nursing standard 1. Is the problem w ithin your sphere of responsibility? Can you do something about it? 2. Is it a situation that can be improved w ithin a reasonable amount of tim e and w ith a reasonable amount o f work? 3. W ill the result be a direct improvement in patient care? 4. H ow will you demonstrate the improvement? 5. W ill you be able to identify a range o f structure, process and outcome criteria and agree a standard? 6. Do all staff share the same o r similar views about the need to look at this topic? Source: Kitson (1988)
684
dards.-1 referred to Kitson’s (1988) checklist to ensure that the topic ‘palliative care’ was suitable (Table 1). My responses to the checklist were all in the affirmative. I then undertook a literature search on the two main topics: palliative care and standard setting. I concluded that one stan dard alone was not sufficient to represent palliative care adequately as it is a very wide subject. A group of standards was therefore needed; however, before writing them, it was essential to develop a philosophy of care (RCN, 1981). Addison ward already had a ward philos ophy, and the staff and I felt that the palli ative care philosophy could be developed from this. A philosophy should state the beliefs and values of all staff (RCN, 1981). Our aim has always been to deliver the highest possible care that we can give rather that what we do give. However, Kitson (1986) recommends five points that must be taken into account when developing nursing standards. These are adapted and summarized in Table 2.
Developing a philosophy
In order to develop a palliative care philos ophy 1 had many informal chats with all grades of staff and we shared thoughts and ideas about palliative care. 1 also consulted other members of the multidisciplinary team, e.g. doctors, physiotherapists and the support team (Table J). The ward philosophy, staff’s ideas, cur rent literature and the knowledge 1 had gained from the palliative care course all served as a resource for the philosophy. The most important reason for writing the phil osophy was to ensure that all patients who are dying, whether they have cancer or not, receive the best possible care. Harris (1990) confirms that 25% of patients die from can cer and 75% from chronic or acute illness, therefore palliative care is vital for all pa tients, not just cancer patients. The staff on the ward also felt that the patient who re-
British Journalbyof154.059.124.102 Nursing, 1992, on VolJanuary I,No 1310, 2019. Downloaded from magonlinelibrary.com
Developing standards in palliative care quires palliative care for a chronic illness deserves as much support and help as a pa tient with cancer. The established principles of care developed by the hospice movement should guide the management of care and services for all dying patients (Harris, 1990). Our palliative care philosophy is shown in Table 4.
Standards
We created seven standards (Table 5) based on the hospice concept of care ‘living with dying’. To ensure continuity throughout the hospital, we utilized the Dynamic Standard Setting System (DySSSy) which was devel oped by Kitson et al (1990) from T a b le 2. R e c o m m e n d a tio n s fo r d e v e lo p in g nursing standards Realistic
The standards should be w ritte n by staff who are going to develop the care, rather than be imposed.
Understandable A ll grades o f staff should understand the standard o f care required. Clear, simple wording and phrases should be used.
Measurable
A suitable audit to ol must be devised to m onitor the level of care delivered.
Believable
The standards should be formulated by practitioners who are familiar w ith and updated about the clinical content involved. They should also reflect multiple aspects o f patient status, e.g. psychological, physiological and social needs.
Achievable
A ll staff must feel that they can provide the level o f care described.
Adapted from Kitson (1986)
T a b le 3. T h e re c o m m e n d a tio n s t h a t w a rd s ta ff w ished to include in th e philosophy and standards o f p a llia tiv e care Palliation o f physical symptoms Alleviation o f anxiety, fear and isolation Maintenance o f independence fo r as long as possible A dignified and peaceful death Support fo r family, friends and staff following bereavement Inclusion o f all patients requiring palliative care, not just those w ith cancer Introduction o f a resource pack to include pain assessments, relevant current literature and control o f distressing symptoms Reduction in nurses’ stress by ensuring all staff are able to supply, if necessary, information to relatives on making wills, funeral arrangements and counselling
British Journal of Nursing, 1992,Voi l,N ol3
Donabedian’s (1966) structure, process and outcome model. This system has the funda mental principle that setting standards is a dynamic process whereby the standard of care will constantly improve and therefore become self-perpetuating. Each statement can be broken down into the following four criteria: Structure This relates to the resources in the system that are necessary for the completion of the task under review, e.g. buildings, equip ment, ancillary services, rules and regula tions and staff. Process This relates to the actions undertaken by staff, e.g. assessment techniques, documen tation systems, describing nursing actions in implementing care and patient/carer edu cation. Outcome This describes the desired effect of nursing care in terms of patient behaviour, re sponses, level of knowledge and health status. Monitoring This describes the method used and people involved in checking that the patient is re ceiving and has received the appropriate care according to the written standards. Kitson (1986) recommends two types of monitoring, i.e. retrospective review or concurrent review. Retrospective review analyses the patient’s care after discharge. Concurrent review takes place while the pa tient is receiving care and is an ongoing analysis of the care delivered. It was de cided that the latter would be the most ap propriate way to monitor the standards. A checklist was devised in which all the im portant aspects of care are listed and each team leader decides how often the checklist should be completed, e.g. on each shift, daily, weekly or monthly, depending on the patient’s condition. The ward sister and I propose to audit the checklist, care plans and evaluations of all patients receiving pal liative care every 2-3 months. Once the standards had been written, a meeting was arranged with a representative from each grade of staff in attendance. The philosophy and standards were read and changed where necessary. Staff wanted to improve the follow-up care of relatives following bereavement. It was felt that we could improve our method of giving information to relatives after their loved one had died. We have always given
685
Downloaded from magonlinelibrary.com by 154.059.124.102 on January 10, 2019.
Developing standards in palliative care (Choosing a suitable word for the next of kin in the standards proved difficult as we wanted to include relatives, friends, significant others and nearest and dearest. Eventually we decided to use the word ‘family’. . . . 5
T ab le 4. T h e p a llia tiv e care philosophy o f A ddision w a rd Each patient is an individual w ith unique physical, psychological, social and spiritual needs and w ith personal ties to a family o r o the r social netw ork. Therefore, our care and approaches must be holistic and consider the patient and the family o r o th e r carers as the central focus. Once diagnosis has been achieved, and a cure is unobtainable, palliative care becomes the p riority. The principal aim is to ‘add life to years, not years to life’ (Denham, 1987). Patients and th e ir ‘nearest and dearest’ need continual support and we are comm itted to helping them live realistically w ith their terminal diagnosis, be it cancer o r any o the r terminal disease, e.g. end-stage heart failure. Patients' wishes w ill always be respected and no one may make a decision fo r a patient if he is com petent in doing it himself. The nurse w ill be the patients’ advocate and w ill ‘m on itor informed consent, provide patients w ith information on alternatives, mediate on the patients’ behalf, act as a co-ordinator o f care and as the facilitator o f care’ (Davis, 1988). Everyone is encouraged to live w ithin th e ir limitations and to make the most o f their potential each day. Patients have a right to die w ith dignity and we endeavour to support them to a dignified and peaceful death, and to support the family and staff during and after this distressing experience. W e acknowledge the special needs o f the family coping w ith terminal disease and we aim to relieve symptoms, prom ote com fort, prevent stress and create an atmosphere o f knowledgeable, friendly and helpful concern. W e w ill coordinate all the members o f the multidisciplinary team, including the Guy’s support team and community teams, w ith the patients’ wishes always paramount in our minds. W e have a responsibility to provide accurate and appropriate information to our patients and th e ir families; they have the right to be involved in decisions regarding care and to be supported in their decisions. W e recognize the dynamics o f intense and stressful interpersonal relationships which occur when caring fo r dying patients and their families and are com m itted to supporting our colleagues. The staff are individually accountable fo r com petent practice and this is accomplished by the constant updating and expansion o f knowledge, skills and attitudes. The expertise o f o th e r disciplines and the importance o f collaboration w ith o the r members of the healthcare team w ithin the hospital and the community is recognized. W e endorse the importance o f research as a basis fo r improvement o f care and recognize our responsibility to initiate and cooperate in research-based care, as well as to implement the findings. Copyright Addison ward, Cuy's Hospital. London
information verbally, but according to O ’Brien (1988), written information is vital as a reinforcement of verbal information. In addition, it allows relatives to absorb the information in their own time and then ask questions if necessary. A draft letter has also been written and each team uses this as a guideline for their own handwritten, personal letters which they send to relatives along with supporting information. We also decided to contact the relatives within 2 weeks of the patient’s death. It is the responsibility of the team leader and team to arrange this.
Difficulties
A vast amount of time and effort was in volved in reading the literature, creating the standards and organizing meetings so that staff could attend without compromising
686
patient care. Devising the monitoring tool proved more difficult than expected as it needed to be simple yet cover all aspects of care. Choosing a suitable word for the next of kin in the standards proved difficult as we wanted to include relatives, friends, sig nificant others and nearest and dearest. Eventually we decided to use the word ‘family’ with an explanation that ‘Family should be taken to indicate persons/animals who are defined by the in dividual requiring palliative care as hav ing a significant place in his/her life.’ There was much discussion over where to keep the audit tool. We eventually de cided to keep it with the care plan in the patient’s folder, if the patient was in agree ment, as it can then be completed easily by British Journal of Nursing, 1992, Vol I,No 13
Downloaded from magonlinelibrary.com by 154.059.124.102 on January 10, 2019.
Developing standards in palliative care staff in conjunction with the patient. In the future, we hope to adapt one of our side wards into a quiet, peaceful area where rela tives can wait in comfort and talk with staff. We intend to buy comfortable chairs and have curtains instead of blinds.
Conclusion
We are currently in the process of imple menting the palliative care philosophy and standards for a trial period of 6 months, after which they will be reviewed and evaluated with changes made as required. From my experience of creating these stan dards, I would make the following recom mendations to anyone who is contemplat ing standard setting: 1. Ensure that you have the support of your ward sister and senior nurse. Table 5. T he standards o f p a llia tive care 1. Physical symptoms which impair the patients’ ability to function to their optim um ability w ill be relieved. 2. Stressors which threaten the breakdown o f the social support system w ill be reduced, therefore facilitating open and honest communication between patient and carers. 3. Nursing staff w ill coordinate all care and ensure continuity o f care by liaising w ith o the r healthcare professionals, statutory and voluntary agencies. 4. Independence w ill be maintained fo r as long and as comfortably as possible, taking into account the patient’s right to die w ith dignity. 5. The dying patient w ill receive social, spiritual, emotional and psychological support to enable a peaceful and dignified death. 6. A ll nurses w ill ensure that the dignity o f the deceased patient is preserved and the last offices w ill be performed in a safe manner, taking into account the rites o f the deceased patient’s religion. 7. The relatives, carers, staff and other patients w ill feel supported following a patient’s death.
2. Know where to find help in writing and measuring the standards. 3. Make sure that ward staff know what you are doing and give them every op portunity to discuss ideas with you. I found informal chats on a one-to-one basis invaluable. 4. Set a time limit on the first attempt otherwise it becomes masses of paper work and never gets implemented. 5. Have frequent review dates to set an other objective. 6. Plan the whole idea in small stages and review each stage regularly, e.g. my stages were discussing ideas, writing the philosophy, creating standards statements, completing the process and outcome criteria, creating an audit tool, and implementing the standards. 7. Use ‘he’ for patient and ‘she’ for nurse with an explanation at the beginning as it makes reading so much easier. 8. Ensure that you have good keyboard skills and access to a word processor or typewriter. 9. Find out whether anyone else has writ ten standards on your particular topic and adapt and change this as necessary. 10. Do not become too immersed in struc ture, process and outcome. It can be difficult to decide which criteria go un der which heading. The copyright to Tables 4 and 5 is held by Addison ward, Guy's Hospital, Lon don. Information or advice on these standards can be obtained from Lesley Marsh on Addison ward.
Copyright Addison ward, Guy's Hospital, London
KEY POINTS • Palliative care is an area of nursing that demands special skills and deserves standards of excellence. • Standards are vital for the monitoring of patient care. • Standards ensure that all staff are aware of the level of care to be delivered. • Palliative care should be given to all patients who are dying, not just those with cancer. • Before standards can be created, a philosophy of care must be written. • Time limits must be set and adhered to.
British Journal ol Nursing, 1992, Vol I,No 13
Davis AJ (1988) The clinical nurse’s role in informed consent. / l'rof N un 4(2): 88-91 Denham MJ (1987) Care o f the Long-Stay Elderly Pa tient. Croom Helm, London Dbnabedian A (1966) Evaluating the quality of medi cal care. Atillhank Memorial Fund Quarterly 44(2): 166-206 Harris L (1990) The disadvantaged dying. Nurs Times 86(22): 26 Kitson A, Kendall H (1986) Rest assured. Nurs Times 82: 29-31 Kitson A (1988) Steps to Setting Achievable Nursing Standards. RCN Standards of Care Project, Lon don Kitson AL, Hvndman SJ, Harvey G, Yerrell PH (1990) Quality Patient Care: The Dynamic Stan dard Setting system. Scutari, Harrow O ’Brien MJ (1988) Communications and Relationships in Nursing (2nd edn). CV Mosby, Missouri RCN (1981) Towards Standards — A Discussion Document. RCN, London Schofield J (1990) Practical standards. Nurs Times 86(8): 31-3
687
Downloaded from magonlinelibrary.com by 154.059.124.102 on January 10, 2019.
Developing standards in palliative care
w
Lesley Marsh, Guy’s Hospital, London
Palliative care for cancer patients has improved dramatically in recent years. Such care also benefits patients dying from chronic illnesses. This article explains how nursing standards were written for patients with cancer and acute and chronic illnesses requiring palliative care. Miss Marsh is a Staff Nurse at Guy’s Hospital, St Thomas Street, London SEl 9RT
W W hilc undertaking the 3-month palliative care course at the Nightingale and Guy’s College of Health earlier this year, I was challenged by the course tutor to im prove an area of palliative care within the acute assessment and rehabilitation elderly care ward where I work (Addison ward), as many of the patients are in hospital for long periods and many receive palliative care. Although we did not monitor the level of palliative care that we were delivering, we instinctively considered it to be of a high standard. However, we decided to create a philosophy and produce written stan dards of care to help us define the quality of care we could and should deliver. Schofield (1990) supports the view that setting explicit standards raises care to the highest level and allows every member of the ward team to know exactly what is ex pected of him/her. Standard setting ensures that nursing care is constantly evaluated and updated so that the practice of nursing moves towards excellence.
Background
After discussion with my ward sister, sen ior nurse and ward staff, I coordinated all of their ideas and began to draft the stan Table I. C hecklist to consult when selecting a topic fo r a nursing standard 1. Is the problem w ithin your sphere of responsibility? Can you do something about it? 2. Is it a situation that can be improved w ithin a reasonable amount of tim e and w ith a reasonable amount o f work? 3. W ill the result be a direct improvement in patient care? 4. H ow will you demonstrate the improvement? 5. W ill you be able to identify a range o f structure, process and outcome criteria and agree a standard? 6. Do all staff share the same o r similar views about the need to look at this topic? Source: Kitson (1988)
684
dards.-1 referred to Kitson’s (1988) checklist to ensure that the topic ‘palliative care’ was suitable (Table 1). My responses to the checklist were all in the affirmative. I then undertook a literature search on the two main topics: palliative care and standard setting. I concluded that one stan dard alone was not sufficient to represent palliative care adequately as it is a very wide subject. A group of standards was therefore needed; however, before writing them, it was essential to develop a philosophy of care (RCN, 1981). Addison ward already had a ward philos ophy, and the staff and I felt that the palli ative care philosophy could be developed from this. A philosophy should state the beliefs and values of all staff (RCN, 1981). Our aim has always been to deliver the highest possible care that we can give rather that what we do give. However, Kitson (1986) recommends five points that must be taken into account when developing nursing standards. These are adapted and summarized in Table 2.
Developing a philosophy
In order to develop a palliative care philos ophy 1 had many informal chats with all grades of staff and we shared thoughts and ideas about palliative care. 1 also consulted other members of the multidisciplinary team, e.g. doctors, physiotherapists and the support team (Table J). The ward philosophy, staff’s ideas, cur rent literature and the knowledge 1 had gained from the palliative care course all served as a resource for the philosophy. The most important reason for writing the phil osophy was to ensure that all patients who are dying, whether they have cancer or not, receive the best possible care. Harris (1990) confirms that 25% of patients die from can cer and 75% from chronic or acute illness, therefore palliative care is vital for all pa tients, not just cancer patients. The staff on the ward also felt that the patient who re-
British Journalbyof154.059.124.102 Nursing, 1992, on VolJanuary I,No 1310, 2019. Downloaded from magonlinelibrary.com
Developing standards in palliative care quires palliative care for a chronic illness deserves as much support and help as a pa tient with cancer. The established principles of care developed by the hospice movement should guide the management of care and services for all dying patients (Harris, 1990). Our palliative care philosophy is shown in Table 4.
Standards
We created seven standards (Table 5) based on the hospice concept of care ‘living with dying’. To ensure continuity throughout the hospital, we utilized the Dynamic Standard Setting System (DySSSy) which was devel oped by Kitson et al (1990) from T a b le 2. R e c o m m e n d a tio n s fo r d e v e lo p in g nursing standards Realistic
The standards should be w ritte n by staff who are going to develop the care, rather than be imposed.
Understandable A ll grades o f staff should understand the standard o f care required. Clear, simple wording and phrases should be used.
Measurable
A suitable audit to ol must be devised to m onitor the level of care delivered.
Believable
The standards should be formulated by practitioners who are familiar w ith and updated about the clinical content involved. They should also reflect multiple aspects o f patient status, e.g. psychological, physiological and social needs.
Achievable
A ll staff must feel that they can provide the level o f care described.
Adapted from Kitson (1986)
T a b le 3. T h e re c o m m e n d a tio n s t h a t w a rd s ta ff w ished to include in th e philosophy and standards o f p a llia tiv e care Palliation o f physical symptoms Alleviation o f anxiety, fear and isolation Maintenance o f independence fo r as long as possible A dignified and peaceful death Support fo r family, friends and staff following bereavement Inclusion o f all patients requiring palliative care, not just those w ith cancer Introduction o f a resource pack to include pain assessments, relevant current literature and control o f distressing symptoms Reduction in nurses’ stress by ensuring all staff are able to supply, if necessary, information to relatives on making wills, funeral arrangements and counselling
British Journal of Nursing, 1992,Voi l,N ol3
Donabedian’s (1966) structure, process and outcome model. This system has the funda mental principle that setting standards is a dynamic process whereby the standard of care will constantly improve and therefore become self-perpetuating. Each statement can be broken down into the following four criteria: Structure This relates to the resources in the system that are necessary for the completion of the task under review, e.g. buildings, equip ment, ancillary services, rules and regula tions and staff. Process This relates to the actions undertaken by staff, e.g. assessment techniques, documen tation systems, describing nursing actions in implementing care and patient/carer edu cation. Outcome This describes the desired effect of nursing care in terms of patient behaviour, re sponses, level of knowledge and health status. Monitoring This describes the method used and people involved in checking that the patient is re ceiving and has received the appropriate care according to the written standards. Kitson (1986) recommends two types of monitoring, i.e. retrospective review or concurrent review. Retrospective review analyses the patient’s care after discharge. Concurrent review takes place while the pa tient is receiving care and is an ongoing analysis of the care delivered. It was de cided that the latter would be the most ap propriate way to monitor the standards. A checklist was devised in which all the im portant aspects of care are listed and each team leader decides how often the checklist should be completed, e.g. on each shift, daily, weekly or monthly, depending on the patient’s condition. The ward sister and I propose to audit the checklist, care plans and evaluations of all patients receiving pal liative care every 2-3 months. Once the standards had been written, a meeting was arranged with a representative from each grade of staff in attendance. The philosophy and standards were read and changed where necessary. Staff wanted to improve the follow-up care of relatives following bereavement. It was felt that we could improve our method of giving information to relatives after their loved one had died. We have always given
685
Downloaded from magonlinelibrary.com by 154.059.124.102 on January 10, 2019.
Developing standards in palliative care (Choosing a suitable word for the next of kin in the standards proved difficult as we wanted to include relatives, friends, significant others and nearest and dearest. Eventually we decided to use the word ‘family’. . . . 5
T ab le 4. T h e p a llia tiv e care philosophy o f A ddision w a rd Each patient is an individual w ith unique physical, psychological, social and spiritual needs and w ith personal ties to a family o r o the r social netw ork. Therefore, our care and approaches must be holistic and consider the patient and the family o r o th e r carers as the central focus. Once diagnosis has been achieved, and a cure is unobtainable, palliative care becomes the p riority. The principal aim is to ‘add life to years, not years to life’ (Denham, 1987). Patients and th e ir ‘nearest and dearest’ need continual support and we are comm itted to helping them live realistically w ith their terminal diagnosis, be it cancer o r any o the r terminal disease, e.g. end-stage heart failure. Patients' wishes w ill always be respected and no one may make a decision fo r a patient if he is com petent in doing it himself. The nurse w ill be the patients’ advocate and w ill ‘m on itor informed consent, provide patients w ith information on alternatives, mediate on the patients’ behalf, act as a co-ordinator o f care and as the facilitator o f care’ (Davis, 1988). Everyone is encouraged to live w ithin th e ir limitations and to make the most o f their potential each day. Patients have a right to die w ith dignity and we endeavour to support them to a dignified and peaceful death, and to support the family and staff during and after this distressing experience. W e acknowledge the special needs o f the family coping w ith terminal disease and we aim to relieve symptoms, prom ote com fort, prevent stress and create an atmosphere o f knowledgeable, friendly and helpful concern. W e w ill coordinate all the members o f the multidisciplinary team, including the Guy’s support team and community teams, w ith the patients’ wishes always paramount in our minds. W e have a responsibility to provide accurate and appropriate information to our patients and th e ir families; they have the right to be involved in decisions regarding care and to be supported in their decisions. W e recognize the dynamics o f intense and stressful interpersonal relationships which occur when caring fo r dying patients and their families and are com m itted to supporting our colleagues. The staff are individually accountable fo r com petent practice and this is accomplished by the constant updating and expansion o f knowledge, skills and attitudes. The expertise o f o th e r disciplines and the importance o f collaboration w ith o the r members of the healthcare team w ithin the hospital and the community is recognized. W e endorse the importance o f research as a basis fo r improvement o f care and recognize our responsibility to initiate and cooperate in research-based care, as well as to implement the findings. Copyright Addison ward, Cuy's Hospital. London
information verbally, but according to O ’Brien (1988), written information is vital as a reinforcement of verbal information. In addition, it allows relatives to absorb the information in their own time and then ask questions if necessary. A draft letter has also been written and each team uses this as a guideline for their own handwritten, personal letters which they send to relatives along with supporting information. We also decided to contact the relatives within 2 weeks of the patient’s death. It is the responsibility of the team leader and team to arrange this.
Difficulties
A vast amount of time and effort was in volved in reading the literature, creating the standards and organizing meetings so that staff could attend without compromising
686
patient care. Devising the monitoring tool proved more difficult than expected as it needed to be simple yet cover all aspects of care. Choosing a suitable word for the next of kin in the standards proved difficult as we wanted to include relatives, friends, sig nificant others and nearest and dearest. Eventually we decided to use the word ‘family’ with an explanation that ‘Family should be taken to indicate persons/animals who are defined by the in dividual requiring palliative care as hav ing a significant place in his/her life.’ There was much discussion over where to keep the audit tool. We eventually de cided to keep it with the care plan in the patient’s folder, if the patient was in agree ment, as it can then be completed easily by British Journal of Nursing, 1992, Vol I,No 13
Downloaded from magonlinelibrary.com by 154.059.124.102 on January 10, 2019.
Developing standards in palliative care staff in conjunction with the patient. In the future, we hope to adapt one of our side wards into a quiet, peaceful area where rela tives can wait in comfort and talk with staff. We intend to buy comfortable chairs and have curtains instead of blinds.
Conclusion
We are currently in the process of imple menting the palliative care philosophy and standards for a trial period of 6 months, after which they will be reviewed and evaluated with changes made as required. From my experience of creating these stan dards, I would make the following recom mendations to anyone who is contemplat ing standard setting: 1. Ensure that you have the support of your ward sister and senior nurse. Table 5. T he standards o f p a llia tive care 1. Physical symptoms which impair the patients’ ability to function to their optim um ability w ill be relieved. 2. Stressors which threaten the breakdown o f the social support system w ill be reduced, therefore facilitating open and honest communication between patient and carers. 3. Nursing staff w ill coordinate all care and ensure continuity o f care by liaising w ith o the r healthcare professionals, statutory and voluntary agencies. 4. Independence w ill be maintained fo r as long and as comfortably as possible, taking into account the patient’s right to die w ith dignity. 5. The dying patient w ill receive social, spiritual, emotional and psychological support to enable a peaceful and dignified death. 6. A ll nurses w ill ensure that the dignity o f the deceased patient is preserved and the last offices w ill be performed in a safe manner, taking into account the rites o f the deceased patient’s religion. 7. The relatives, carers, staff and other patients w ill feel supported following a patient’s death.
2. Know where to find help in writing and measuring the standards. 3. Make sure that ward staff know what you are doing and give them every op portunity to discuss ideas with you. I found informal chats on a one-to-one basis invaluable. 4. Set a time limit on the first attempt otherwise it becomes masses of paper work and never gets implemented. 5. Have frequent review dates to set an other objective. 6. Plan the whole idea in small stages and review each stage regularly, e.g. my stages were discussing ideas, writing the philosophy, creating standards statements, completing the process and outcome criteria, creating an audit tool, and implementing the standards. 7. Use ‘he’ for patient and ‘she’ for nurse with an explanation at the beginning as it makes reading so much easier. 8. Ensure that you have good keyboard skills and access to a word processor or typewriter. 9. Find out whether anyone else has writ ten standards on your particular topic and adapt and change this as necessary. 10. Do not become too immersed in struc ture, process and outcome. It can be difficult to decide which criteria go un der which heading. The copyright to Tables 4 and 5 is held by Addison ward, Guy's Hospital, Lon don. Information or advice on these standards can be obtained from Lesley Marsh on Addison ward.
Copyright Addison ward, Guy's Hospital, London
KEY POINTS • Palliative care is an area of nursing that demands special skills and deserves standards of excellence. • Standards are vital for the monitoring of patient care. • Standards ensure that all staff are aware of the level of care to be delivered. • Palliative care should be given to all patients who are dying, not just those with cancer. • Before standards can be created, a philosophy of care must be written. • Time limits must be set and adhered to.
British Journal ol Nursing, 1992, Vol I,No 13
Davis AJ (1988) The clinical nurse’s role in informed consent. / l'rof N un 4(2): 88-91 Denham MJ (1987) Care o f the Long-Stay Elderly Pa tient. Croom Helm, London Dbnabedian A (1966) Evaluating the quality of medi cal care. Atillhank Memorial Fund Quarterly 44(2): 166-206 Harris L (1990) The disadvantaged dying. Nurs Times 86(22): 26 Kitson A, Kendall H (1986) Rest assured. Nurs Times 82: 29-31 Kitson A (1988) Steps to Setting Achievable Nursing Standards. RCN Standards of Care Project, Lon don Kitson AL, Hvndman SJ, Harvey G, Yerrell PH (1990) Quality Patient Care: The Dynamic Stan dard Setting system. Scutari, Harrow O ’Brien MJ (1988) Communications and Relationships in Nursing (2nd edn). CV Mosby, Missouri RCN (1981) Towards Standards — A Discussion Document. RCN, London Schofield J (1990) Practical standards. Nurs Times 86(8): 31-3
687
Downloaded from magonlinelibrary.com by 154.059.124.102 on January 10, 2019.
