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Establishing a nurse practitioner collaborative: evolution,
development,
and outcomesKaren Quinn, Peter Hudson
The advanced clinical practice role of the nurse practitioner
(NP) has been well established in North America for several decades
and across a range of specialties (Ryan- Woolley et al, 2007;
Poghosyan et al, 2012). The NP role in Australia and the UK is a
relatively new initiative that commenced in the early 2000s
(Gardner et al, 2009). There are over 1000 NPs across all states
and territories of Australia, of whom approximately 130 work in the
state of V ictoria (Victorian Governm ent Health Information,
2012). Australian NPs work across a range of specialties, including
palliative, emergency, older person, renal, cardiac, respiratory,
and mental health care.
There has been increasing focus nationally and internationally
on developing academic programmes specifically for nurses working
toward NP status (Gardner et al, 2006). There has been less
emphasis on identifying the comprehensive clinical support
requirements for NPs and NP candidates (NPCs) to ensure they meet
all registration requirements to achieve and/or maintain
endorsement, or on articulating the ongoing requirements for NPs
once endorsed.
Historically in Australia there has been a lack of clarity and
limited published evidence on the benefits of the NP role for
patients, carers, and health services (Quaglietti et al, 2004;
Gardner and Gardner, 2005; Bookbinder et al, 2011; Dyar et al,
2012). An NP is considered to be at the apex of clinical nursing
practice. The NP role typically entails comprehensively assessing
and managing patients, prescribing medicines, making direct
referrals to other specialists and services, and ordering
diagnostic investigations (Australian Nursing and Midwifery
Council, 2009).
All NPs in Australia are required to meet the following generic
criteria: be a registered nurse, have completed a Nursing and
Midwifery Board of Australia approved postgraduate university
Masters (nurse practitioner) degree programme, and be able to
demonstrate a minimum of 3 years experience in an advanced practice
role
AbstractThe firs t Australian palliative care nurse p rac
titione r (NP) was endorsed in 2003. In 2009 the Victoria
Department of Health funded the development of the Victorian
Palliative Care Nurse Practitioner Collaborative (VPCNPC). Its aim
was to promote the NP role, develop resources, and provide
education and m entorship to NPs, nurse practitioner candidates
(NPCs), and health service managers. Four key objectives were
developed: identify the demographic pro file o f palliative care
NPCs in Victoria; develop an education curriculum and practical
resources to support the training and education o f palliative care
NPCs and NPs; provide mentorship to NPs, NPCs, and service
managers; and ensure e ffective com m un ica tion w ith all key
stakeholders. An NPC survey was also conducted to explore NPC
demographics, models of care, the hours of study required for the
role, the mentoring process, and education needs.This paper reports
on the establishm ent o f the VPCNPC, the steps taken to achieve
its objectives, and the results of the survey.The NP role in
palliative care in Australia continues to evolve, and the VPCNPC
provides a structure and resources to clearly articulate the
benefits of the role to nursing and clinical services.Key words:
Nurse practitioner Collaborative Palliative care Advanced nursing
Education
(Nursing and Midwifery Board of Australia, 2011). An NPC in
Victoria is a registered nurse employed by a service or
organisation to work toward meeting the academic and clinical
requirements for national endorsement as an NP. During the period
of candidacy, which is of variable duration, NPCs consolidate their
competence to work at the advanced practice level of an NP. The
candidacy period is a process of learning the new role while
engaging with mentors (medical and nursing) and accessing other
learning opportunities both within and outside ones organisation to
meet the educational requirements. Integral to the NP role is the
development of a model of care that is responsive to identified
service delivery gaps that can be addressed by the skills,
knowledge, and expertise of an NP. These are unique to each
individual service. The practice of an
Karen Quinn,Coordinator Education, Centre for Palliative Care;
Project Officer, Victorian Palliative Care Nurse Practitioner
Collaborative, PO Box 2900, St Vincents Hospital Melbourne,
Australia; Peter Hudson, Director, Centre for Palliative Care, St
Vincents Hospital Melbourne; Professor of Palliative Care, Queens
University, Belfast, Northern Ireland
Correspondence to: Karen Quinn karen.quinn@ svhm.org.au
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T a b le 1. A c t io n s a n d o u tc o m e s r e la te d to V P
C N P C o b je c tiv e s
Objective Action O utcom e
Identify the
demographic profile
and learning and
mentorship needs of Survey distributed
7 o f 13 NPCs responded
Majority aged 40-50 years
Mean o f 1 1 years o f palliative care
experience
*> Over half o f NPCs are full-time NPCs
NPCs enrolled in Masters courses
allocate 20-27 hours/week o f own
time to study
Majority review patients in aged care
palliative ca*e NPCs to NPCs in facilities
in V ictoria V ictoria Clearly identified learning needs
Develop an
education curriculum
and practical
resources to support Lead quarterly
Professional networking opportunities
Avenue fo r sharing experiences and
concerns
a Case study presentation opportunities
the training and forums Palliative Care NP Clinical
education c f Identify ongoing Competencies
palliative ca-e NPCs learning e Palliative Care NP Symptom
and NPs resource needs Assessment Guide
Provide mentorship
to NPs, NPCs, and Appoin t mentors
Position descriptions developed
Regular evaluation of number and
service maragers fo r each group nature o f enquiries
Ensure effective
Develop website
Consider other
Website acts as repository fo r resources
Regular e-newletters to all members
Special interest group for NPs and NPCs
communication w ith communication Online discussion forum
all key stakeholders strategies Map o f NPs and NPCs
NPC, nurse practitioner candidate; NP, nurse
practitioner;VPCNPC,Victorian Palliative
Care Nurse Practitioner Collaborative
Australian NP is guided by national standard; {Nursing and
Midwifery Board of Australia 2014). It is defined by four
overarching standards: clinical, education, research, and
leadership.
Following the initial endorsement of four Victorian palliative
care NPs in 2005, there was a lull in recruitment. The Victoria
Department of Health (DH) recognised the potential benefits of NPs
for health services, and in 2008 it provided funding for Victorian
public health services to scope palliative care NP models of care
that could enhance service delivery and patient outcomes. The
scoping strategy was effective and led to the appointment of 16
palliative care nurses to NPC positions over the ensuing 3 years.
The NPC; work across a broad range of care settings, including
inpatient, community, and outpatient in metropolitan, regional, and
rural areas of Victoria.
At the same time, the DH also funded the Centre for Palliative
Care to establish the Victorian Palliative Care Nurse Practitioner
Collaborative (VPCNPC) to support the NPs and NPCs. The Centre is a
state-wide service that i; part of St Vincents Hospital Melbourne
and a
collaborative Centre of the University of Melbourne. Its primary
function is to provide training and conduct research in palliative
care. The purpose of the VPCNPC was to provide support and
mentorship and develop resources targeted at palliative care NPs,
NPCs, and health service managers. Membership of the VPCNPC is open
to all NPs, NPCs, health service managers, and nurses interested in
the NP role.
The aim of this paper is to describe the development of the
VPCNPC, its actions, and the outcomes of these actions.
Development of the VPCNPCThe initial step for the VPCNPC was to
establish a governance structure, which included appointing a
management committee to oversee and provide advice on all
activities. Key stakeholders were invited onto the management
committee, which went on to comprise a representative from the DH,
an experienced palliative care NP engaged as a clinical advisor, a
clinical health service manager, a community palliative care
service representative, a palliative care physician, an academic,
and a project officer.
The management committee developed four objectives to inform the
strategic direction of the VPCNPC and guide its activities:
Identify the demographic profile, including the
learning and mentorship needs, of palliative care NPCs in
Victoria
Develop an education curriculum and practical resources to
support the training and education of palliative care NPCs and
NPs
Provide mentorship to NPs, NPCs, and service managers
Ensure effective communication with all key stakeholders.
Actions and outcomesTable 1 provides a summary of actions and
outcomes related to each of the four objectives.
Demographic profile and learning and mentor needs of palliative
care NPCs in VictoriaA survey was developed by the VPCNPC
management group to determine the demographic profile of palliative
care NPCs, the range and diversity of NPC models of care across
Victoria, the hours of study required for the role, mentoring
arrangements, and NPC education needs. The survey received ethical
approval from St Vincents Hospital Melbourne and was mailed to the
13 current NPCs. Seven NPCs completed the survey.
Three of the seven NPCs were male and five were 40-50 years of
age. They had been regis-
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tered nurses for 13-33 years (mean 22 years) and had been
working in palliative care for 4-19 years (mean 11 years). Four
candidates held postgraduate qualifications other than NP Masters
degrees. Four candidates had completed their NP Masters degrees and
three were working toward them. Four candidates worked full-time in
their NPC role and three part-time. These three combined their
part-time NPC role with either a clinical nurse consultant role or
quality assurance project activities. Four NPCs worked in inpatient
settings and three in community settings.
NPCs who were completing their NP Masters degrees were devoting
20-27 hours per week of their own time to study. NPCs who had
completed their NP M asters committed 3-5 hours per week. In terms
of professional development in paid working hours, three candidates
were not allocated any hours for work-related study; the remainder
were allocated 1-10 hours per week.
Four NPCs were able to provide a clear description of their
model of care, which included responsibility for complex symptom
management across a range of settings. Three said their model was
in development. The four models described all involved enhancing
patient or client access to services and symptom review in
residential aged care settings.
All seven NPCs had identified medical mentors. Five stated that
there was no formal process to the medical mentor meetings, while
two reported that the meetings were structured around case study
discussions or informed by clinical experience since the previous
meeting. Two NPCs reported having an identified nursing mentor, but
neither had a structured approach to the meeting schedule or
format. Five candidates were not able to identify a mentor who
could provide clinical leadership and professional support to the
new NPC role.
Education needs identified by the NPCs included development of
skills in conference presentations and preparing conference
abstracts (=3); conducting mental health assessments and learning
about cardiac, respiratory, and neurological illnesses, pathology,
and diagnostics (n=6); development of clinical assessment skills
(n=3); leadership (=2); and opportunities for placement in
specialist areas including mental health, chronic disease, and a
palliative care setting different to their own (=4).
Curriculum and practical resources to support the training and
education of palliative care NPCs and NPsQuarterly 6-hour forums
were established as a face-to-face opportunity for NPs and NPCs to
network with each other, share experiences and
Box I.VPCNPC education curriculum top cs
End-stage ion-malignant diseases, including cardiac, renal, and
respiratory
Conducting a mental health assessment
Conducting a physical assessment
Leadership in palliative care
Management skills in palliati/e care
Literature searching skills
Research considerations
Teaching a- d learning sty as
Palliative c are and adolescent issues
e Advance care planning
Requirements to r prescribing
Preparing and presenting case studies
Understand rg the role o f a m entor
Interpreting abdom nal and chest X-rays
Ethical challenges in palliative care
Preparing fc r pub ic it io r and dissemination
Supportive decision making from theory to practice
challenges, participate in education, and present and discuss
clinical case studies. At each forum the attendees are invited to
identify their learning needs. The responses so far have been
collated and an education strategic plan has been developed. The
plan focuses on ensuring education is clinically relevant and
complements the academic courses undertaken by NPCs (focusing
primarily on the specialty of palliative care practice) as well as
on compiehensively evaluating all education and related
activities.
Invitations to attend the forums are circulated widely to
padiative care N?s, NPCs, nurses interested in the NP role, and
health service managers. As a means of meeting the education needs
identified in objective 1, education sessions are considered a
critical component of each forum. Participants are encouraged to
prov.de feedback on each of "he forums. Responses so far were
collated and formed the oasis of a curriculum tBox 1). Eaca forum
features a case presentation and discuss.on led by one of the NPCs.
The forums provide a unique opportunity for peer support among the
NPs. NPCs, and service managers and enable them t:> practice
their presentation sk ills and learn from each o th e rs
experiences. As the NP role incorporates leadership and teaching as
well as advanced practice, the education sessions include workshops
on leadership, management, teaching strategies, literature
search.ng, and publication advice.
The NPCs consistently reported via forum evaluation reedback
that they were seeking a framework t.aat would provide indicators
of how to achieve the NP clinical competency standards. The VPCNFC
therefore established a core writing group, consisting of
academics, an NP, and a palliative cere nurse to develop Padiative
Care NP Clinical Competencies During the consultation process it
was agreed that the final document would reference and link with
each of the National NP Competency Standards and include key
performance indicators and assessment prin-
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ciples that would provide evidence of competence. All members of
the VPCNPC were invited to review the first draft, which was then
refined. National and international NPs, palliative care
physicians, policy developers, academics, and a pharmacist were
invited to review the second draft. Based on the feedback, the
draft was further refined to the final version of the Palliative
Care NP Clinical Competencies. The document is available via the
Centre for Palliative Care website
(www.centreforpallcare.org.au).
With the aim of providing NPs and NPCs with a guide to
conducting patient symptom assessment, a second document was
developed based on a similar approach to the competencies. The
Palliative Care NP Symptom Assessment Guide is also available via
the Centre for Palliative Care website.
Mentorship for NPs, NPCs, and service managersMentorship is key
to supporting NPCs, NPs, and clinical service managers as they
embed the NP role into a service. Informed by consultation with
experienced palliative care clinicians in the VPCNPC, three
specific mentor roles were developed for medical, nursing, and
palliative care service manager advisors.
The medical advisor was an experienced specialist palliative
care physician whose primary focus was on providing advice for
rural palliative care NP services, which may not have regular
access to a palliative care doctor. In addition, the role
incorporates working with metropolitan services to support the
NP.
The nurse advisor was an endorsed palliative care NP who
provided professional support and advice to rural and metropolitan
NP services and NPCs via phone or email. The nurse advisor assisted
NPs and NPCs to identify and implement their professional
development plans and promoted networking with providers of
palliative care services. They also assisted in developing and
implementing guidelines and policies specific to the NP role.
The clinical service advisor was a manager of a community
palliative care service that employed an NP and was therefore
familiar with the NP role and the process of embedding it in a
service. The service manager responded to queries (usually by phone
or email) from service managers considering an NP or NPC role.
A review of the number of interactions, the approximate time
taken, and the nature of enquiries for the medical, nursing, and
service manager mentors was routinely conducted at each of the
quarterly management meetings. This monitored the demand for
mentorship and ensured it was
sustainable over time and not burdensome to the mentors. Mentor
enquiries primarily related to seeking clarification about the NP
role and how best to source face-to-face clinical mentoring when it
was not readily available in their service. The mentors provided
advice and recommendations for ensuring NP and NPC needs were
met.
Effective communication with all key stakeholdersEffective
communication was vital to ensuring consistency and regular access
to all relevant information regarding VPCNPC activities. The
communication strategy included the following: Development of a
VPCNPC website (http://
centreforpallcare.org/index.php/education/vpc- npc) that is
regularly updated with information and resources relevant to health
services, NPs, NPCs, and nurses interested in finding out more
about the NP role
0 Development of an e-newsletter with updates on upcoming
activities
Formation of a special interest discussion group for NPs and
NPCs
0 Establishment of an online forum for NPs and NPCs to share
experiences and peer support
0 Collation of NP and NPC details including a description of
each model of care, contact details, and proposed date for NPCs to
achieve endorsement that are shared with all NPCs (with
permission)
0 Presentation of VPCNPC updates regularly at relevant
conferences
0 Development of a map of palliative care NP and NPC locations
in Victoria (accessed via the VPCNPC website).
DiscussionThe total number of Victorian NPs and NPCs has
steadily increased since the inception of the VPCNPC in 2009, when
there were four NPs and two NPCs. Although there are still few
palliative care NPs (currently 11) and NPCs (also 11) in Victoria,
there is increasing interest in the role from nurses and clinical
health services.
All NPCs have been offered NP roles with the same organisation
in which they were a candidate, once they have met all the
requirements and been endorsed as an NP. This suggests that the
clinical services were satisfied with the value that the advanced
practice NP role could add to patient and carer outcomes.
The next steps for the VPCNPC include formally evaluating the
experiences of clinical services that employ NPs and NPCs in terms
of benefits and cost-effectiveness. Given that several nurses have
now been working as NPs in excess
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of 2 years, it would be useful to explore their experiences and
recommendations for the benefit of all nurses interested in the
role.
The activities of the VPCNPC have been guided and informed by
the four objectives developed by the management group and by the
needs identified by the VPCNPC members. For example, the
evaluations undertaken at each of the quarterly forums have
informed a curriculum to meet the learning needs of palliative care
NPs and NPCs. The curriculum was further enhanced by the results of
the NPC survey. All VPCNPC education is evaluated by the
participants, and the education programmes were reviewed based on
the feedback responses.
All members of the collaborative value the opportunity for
collegial interaction via a range of strategies, including
face-to-face meetings, the website, peer contact, focused education
sessions, and resources developed specifically to meet their needs.
One useful aspect of the regular forums is the opportunity to
discuss experiences with other NPs and NPCs. Time in each forum is
allocated to collegial discussion (led by an experienced NP) and
sharing of strategies to problem-solve issues of concern that would
not necessarily be identified in a formal education session.
The resources developed by the VPCNPC, including the Palliative
Care NP Clinical Competencies and Assessment Guide, have been
informally evaluated as being useful to NPs and NPCs and are freely
available to all nurses interested in exploring the NP role. A
future project will formally evaluate and revise these
resources.
The information and resource needs of the clinical service
managers continue to emerge as the managers become more familiar
with the NP role. A resource kit for clinical services could be a
valuable tool. This could include examples of effective models of
care developed by other services, questions for services to
consider to inform the need for an NP, clear articulation of the
role and the responsibilities of the service in supporting NPs and
NPCs, contact details for service managers willing to engage with
and mentor services new to the role, and strategies to implement
access to services (e.g. radiology and pathology) not otherwise
available.
Despite being strongly recommended, regular structured nursing
and medical mentorship were not always accessible to the NPs and
NPCs surveyed. Mentoring also varied between NPs and NPCs.
Therefore, services are encouraged to think creatively about ways
to respond to NPCs learning needs. There is a need for increased
clarity about the role of clinical mentorship, the process, and
mentor responsibilities regarding NPC clinical competency
assessment.
The NPC survey was limited by the small sample size, and
therefore the results and recommendations are not necessarily
transferable to a wider cohort. Repeating the survey with a larger
sample, perhaps involving all NPCs and NPs regardless of their
specialty area of practice, may help to determine whether needs
vary across the groups.
ConclusionThe VPCNPC has continued to evolve and grow as NPs,
NPCs, and clinical service managers become more familiar with the
requirements and responsibilities of supporting nurses to achieve
NP competency. It has developed a model and structured education
curriculum and resources that respond to the unique needs of
palliative care NPs, NPCs, and clinical service managers. Further
research is required to evaluate the benefits of the NP to the key
stakeholderspatients, carers, health professionals, and clinical
services, ijpn
Declaration o f interestsThe VPCNPC is funded by the Department
o f Health Victoria. The authors have no conflicts o f interest to
declare.
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Nurses. Standards and Criteria for the Accreditation o f Nursing
and Midwifery Courses Leading to Registration, Enrolment,
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Bookbinder M, Glajchen M, McHugh M et al (2011) Nurse
practitioner-based models of specialist palliative care at home:
sustainability and evaluation of feasibility. J Pain Symptom Manage
41(1): 25-34
Dyar S, Lesperance M, Shannon R, Sloan J, Colon-Otero G (2012) A
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life of patients with metastatic cancer: results of a randomized
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of Australian nurse practitioners: the first national census. Aust
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endorsement as a nurse practitioner. http://bit. lv/lA72VIq
(accessed 11 August 2014)
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practitioner standards for practice. http://bit. lv/loW7PE4
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Poghosyan L, Lucero R, Rauch L, Berkowitz B (2012) Nurse
practitioner workforce: a substantial supply of primary care
providers. Nurs Econ 30(5): 268-74, 294
Quaglietti S, Blum L, Ellis V (2004) The role of the adult nurse
practitioner in palliative care. J Hosp Palliat Nurs 6(4):
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Ryan-Woolley BM, McHugh GA, Luker KA (2007) Prescribing by
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Research roundup
Synopses o f a selection o f recently pub lished research artic
les o f relevance to p a llia tive care.
Measuring Belgian palliative care services on national and
international scales In recognition of the importance of evaluating
palliative care services in a standardised and valid format,
Leemans et al produced a comprehensive set of quality indicators
against which to measure palliative care services across Belgium.
This mixed-methods study combines quantitative analysis and
qualitative interviews to evaluate the quality indicators for their
face validity, feasibility, discriminative power and
usefulness.
There were 85 quality indicators across nine quality domains
relating to standards in physical, psychological and social
treatment and care, coordination and continuity of care, family and
carer support, information, communication and decision making, and
type and structure of care at the end of life. These indicators
were implemented across nine palliative care services across
Belgium, and then measured via questionnaire, and subsequently
interview, by a sample of patien ts (n=l 16), professional
caregivers (n= 121), family carers (n = 193), and physicians
(n=192). The response rate was highest for professional caregivers
(97%), followed by physicians (65%), then patients (56%) and family
carers (56%).
Five (5.9%) of the indicators were evaluated as not being useful
for quality improvement and 20 (23.5%) had too many missing
answers, i.e. feasibility issues. O ther than this, indicators
appeared to be evenly distributed, dem onstrating good
discriminative power. They were also evaluated as being valid in
terms of measuring the relevant quality. Results indicated that
most respondents found the instrument im portant and useful, but
felt that the set of quality indicators should be smaller, while
remaining comprehensive.
In response to the results, one indicator was removed, and the
rest were revised accordingly. The new set is ready for evaluation
and the authors hope that once it is complete and in
systematic use across Belgium, it will be used to evaluate
palliative care services at home and in hospital against national
and international standards, continually improving them to achieve
higher quality care for patients and their families at the end of
life. However, the authors note the need for both researchers and
policy makers to further investigate and identify the optimal
circumstances for quality comparison.
Leemans K, Deliens L, Francke AL, Stichele RV, Van den Block L,
Cohen J (2014) Quality indicators for palliative care services:
mixed-method study testing for face validity, feasibility
discriminative power and usefulness. Palliat Med 2 September [Epub
ahead of print] doi: 10.1177/0269216314546712
Conducting transparent and ethical research in
resource-restricted settings: a Kenyan evaluation Since the
widespread availability of antiretroviral (ART) therapy in sub-
Saharan Africa, no evidence has been collected to evaluate a
holistic model of palliative care for HIV-positive patients
receiving this treatment. To determine the effectiveness of a
nurse-led palliative care approach for this patient group, Lowther
et al conducted a randomised controlled trial (RCT) in an urban
clinic in Mombasa, Kenya. The results of the trial will be
published at a later date. This article presents detailed data
relating to the recruitment process, refusal to participate,
randomisation and missing data in this study in the interest of
transparent reporting, which, the authors note, is particularly
important in cross- cultural settings and when conducting research
with vulnerable populations.
Over 5.5 months, 2070 patients were screened. Inclusion criteria
specified adult HIV-positive patients who had been on ART for more
than 1 month. Of those deemed to be eligible (1664/2070; 80.4% ),
151 (55.7% ) refused to participate and 120 (44.3%) consented. The
intervention consisted of at least seven multidimensional,
person-centred sessions with a trained nurse over a period of 4
months. Data were collected via interview at baseline, and
study
participants (n=120), who were recruited consecutively from the
HIV clinic at the study site, were then allocated to either a
control (n=60) or intervention group (n=60), using block
randomisation.
Participants in the control group received standard HIV care
according to current best practice: assessment by doctors and/or
nurses, repeat prescriptions of ART, referrals to adherence support
for ART and other nutrition or community support referrals as
appropriate. The intervention group received the same standard
care; however, they also received additional sessions with the HIV
nurses who were trained over 8 weeks in the palliative care
approach by the Kenyan Hospice and Palliative Care Association.
The authors, based in the UK and Kenya, concluded that it is
possible to ethically conduct an RCT in a resource- limited
setting. Their findings indicate tha t recruitm ent procedures were
appropriate, missing data were minimal and low participant
attrition indicates the clarity of the informed consent process and
the authors commitment to ethical recruitment procedures.
The authors hope that researchers continue to transparently
report their experiences and that this publication will be used to
inform further RCTs in this area of study.
Lowther K, Higginson IJ, Simms V et al (2014) A randomised
controlled trial to assess the effectiveness of a nurse-led
palliative care intervention for HIV positive patients on
antiretroviral therapy: recruitment, refusal,randomisation and
missing data. BMC Research Notes 7(600): 1-10
UK researchers examine the scope and breadth of social media
platforms to discuss end-of-life care In light of the increasingly
open dialogue, particularly online, around death and dying, Nwosu
et al from the UK conducted a retrospective analysis over 2 years
to analyse its frequency, content, tone and acceleration. Between 1
August 2011 and 31 July 2013, social media analytics tool,
TopsyPro, was used to identify and analyse tweets on
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Twitter containing palliative care terms in the forms of
hashtags or phrases.
Some 13 palliative care terms were identified from a total of
683.5K tweets over a 2-year period. The most popular terms were end
of life (210K) and palliative care (93.8K) and the most popular
hashtag (#) was #hpm (114K) (hospice and palliative medicine). In
terms of acceleration or trending, the term Liverpool Care Pathway
spiked by 55%, peaking in July 2013, as might be expected with the
independent review being published that month.
Tweet volume for all palliative-related terms increased
considerably by 62.3% between the 2011-12 and 2012-13 time points.
TopsyPro allows for analysis of how positive or negative the
sentiment of selected tweets are in relation to the o ther tweets
posted tha t day. Interestingly, 89% of palliative terms were
classified as more positive than all of the terms mentioned on
Twitter during the 2-year study period.
The greatest volume of relevant tweets appeared to be sent from
English- speaking countries, with 58.1% from the USA, 21.8% from
the UK and 6.6% from Canada. However, as only English search terms
were included in the analysis, potentially relevant terms in other
languages were likely missed, as acknowledged by the authors.
The authors concluded that not only are discussions about the
end of life on the rise in volume and frequency, but they are
largely positive. This signals a gradual shift from the taboo
perception of discussions around death, dying and end-of-life care
toward a more open acceptance of this subject.
The authors suggest th a t social media tools, such as Twitter,
provide a novel platform for ongoing dialogue in end-of-life care,
both personally and professionally, and recommend further
qualitative and quantitative analysis of the impact of this digital
discussion on engaging wider society.
Nwosu AC, Debattista M, Rooney C, Mason S (2014) Social media
and palliative medicine: a retrospective 2-year analysis of global
twitter data to evaluate the use of technology to communicate about
issues at the end of life. BMJ Support Palliat Care 2 September
[Epub ahead of print] doi:10.1136/
bmjspcare-2014-000701
The efficacy of the Liverpool Care Pathway in the Netherlands:
barriers and facilitators Although the Liverpool Care Pathway (LCP)
was recently replaced in the UK following concerns about the
tick-box nature of its use, its original aim in the 1990s was to
transfer the gold standard of care provided in UK hospices to other
settings in which dying patients receive care. Raijmakers et al
conducted a qualitative study to investigate its efficacy in the
Netherlands, where it was introduced in 2001.
Telephone interviews were conducted with 28 stakeholders
involved with the implementation of the LCP in the Netherlands.
These included consultants from the Com prehensive Cancer Centre of
the Netherlands (CCCN), palliative care network coordinators and
project leaders of the organisations im plem enting the LCP. The
LCP is in place in over 100 health-care organisations in the
Netherlands. The CCCN consultants, who were asked to identify
organisations that successfully implemented the pathway, mentioned
a total of 25 organisations, 10 of which were selected to guarantee
a variety of geographical regions and organisational settings.
Subsequendy, consecutive focus groups, led by an experienced
moderator, were held with eight interviewees to discuss and
validate the findings from the interviews. All transcripts from
both interviews and focus groups were then transcribed and
thematically analysed.
In a d d itio n to the essen tia l com ponent of ensuring m
otivated health professionals and management to drive the
improvement of end-of-life care, the authors identified
facilitators for successful im plem entation of an instrum ent such
as the LCP as being: quality and completeness of the instrument, a
multidisciplinary project team, and liaison with important parties
within and outside the organisation in which it is being
implemented. However, the authors also recommended that tasks be
disentangled from the project leader and formally integrated into
organisational quality systems.
Raijmakers N, Dekkers A, Galesloot C, van Zuylen L, van der
Heide A (2014) Barriers and facilitators to implementation of the
Liverpool
Care Pathway in the Netherlands: a qualitative study. BMJ
Support Palliat Care 8 September [Epub ahead of print] doi:10.1136/
bmjspcare-2014-000684
Predicting the survival of advanced cancer patients via levels
of consciousness in Taiwan To improve the accuracy of prognoses
given to patients at the end of life, Tsai et al conducted a
prospective observational study to assess the ability of levels of
consciousness to predict the survival of advanced cancer patients,
as a deterioration of consciousness has been reported near
death.
Patients (n=531) were recruited from a palliative care unit in
Taiwan and their status on admission and 1 week later were recorded
as either normal or impaired. Of the 531 patients, 60% (n=317) were
recorded to have normal levels of consciousness at admission. These
patients were found to have a longer survival time than the
remaining 40% (n=214) who were deemed to have impaired
consciousness at admission (17.0 days versus 6.0 days, p
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