The International Journal of Whole Person Care
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Reasons for Returning to the Emergency Department: Perspectives of Patients and the Liaison Nurse Clinician
No full textObjectives: The authors wanted to understand the reasons why patients discharged from internal medicine units return to the emergency department within a short term period. The purpose of the study was to explore patients’ perspective of their reasons for returning to the emergency department within fourteen days post-discharge from an internal medicine unit, and to examine how these reasons relate to those determined by the liaison nurse clinician prior to discharge.Methods: A qualitative descriptive design was selected to develop the study and individual face-to-face semi-structured interviews were conducted with participants. A convenience sample of eight participants was recruited from a major teaching hospital in Montreal, Canada. The study triangulated three different data sources, which were the patient’s perspective through the interview and the liaison nurse clinician’s perspective through the use of two evaluation tools, which were the Bounceback Probability Legend and the LACE Index Scoring Tool.Results: The participants attributed their return to the emergency department due to 1) being discharged too soon, 2) feeling weak at discharge, 3) having limited discharge instructions prior to discharge, and 4) having limited resources available to rely on for help once home. It was also noticed that participants went through a decision-making process for choosing to return to the emergency department. Additionally, the liaison nurse clinician’s evaluation tools identified different reasons from those the participants had attributed to their return to the emergency department.Conclusions: The findings suggest that health care professionals must evaluate and assess patients on several components upon their discharge, such as the understanding of their illness, primary concerns, and readiness prior to discharge. The study provides further data in supporting the need of patient’s involvement in the process of discharge planning
A Role for Cancer Nurses: Responding to Distress in Cancer Patients
No full textBackground: Although all patients experience distress, between 35-45% experience clinically significant levels of distress such as anxiety, depression and adjustment difficulties. Early identification of distress and the provision of relevant interventions is a standard of quality cancer care. Nurses have a critically important role in identifying individuals with distress and providing interventions to manage distress.Objectives: Our objectives are to define the role of cancer nurses in responding to emotional distress experienced by cancer patients and to document the best practices for implementing a program of screening for distress in ambulatory settings.Methods: A programmatic approach to screening for distress (6th vital sign) has been implemented in several cancer facilities across Canada. The program includes protocols for screening, algorithms for assessment, and guidelines for evidenced based interventions. Introduction of the programs have included relevant education of nurses and close attention to uptake and utilization of practice guidelines. Implementation has been mounted within the context of continuous quality improvement and the use of rapid cycle evaluation.Results: Evaluation of successful program implementation has shown increased patient satisfaction with care. Patient concerns provide the focus for opening conversations with individuals and the basis for planning person-centered approaches to care. Patient concerns are identified through the screening maneuver beyond those related to tumor and side effect management. Nurses are in an excellent position to respond to scores on a standardized distress screening tool as part of their patient assessments. The assessments provide a foundation for individualized or tailored interventions.Conclusions: Using a concrete programmatic approach, including screening, focused evidence-based assessment and interventions, offers benefits in achieving person-centered care for cancer patients. In busy clinical settings, an intentional effort is needed to implement a programmatic approach to screening followed by appropriate assessment and intervention
Restoring Core Values: An International Charter for Human Values in Healthcare
No full textBackground: The human dimensions of healthcare are fundamental to the practice of compassionate, safe, and ethical relationship-centered care. Attending to the human dimensions improves patient and clinician satisfaction, outcomes and quality of care; however, these dimensions have not received the emphasis necessary to make them central to every healthcare encounter. We established an international collaborative effort to identify and promote the human dimensions of care.Objectives: a) To describe work to date on the International Charter for Human Values in Healthcare; b) To discuss translation of the Charter’s universal values into education, research, and practice.Methods: An international working group of expert educators, clinicians, linguists, and researchers identified initial values that should be present in every healthcare interaction. The working group and four additional groups -- National Academies of Practice (NAP) USA, International Conference on Communication in Healthcare, Interprofessional Patient-Centered Care Conference, American Academy on Communication in Healthcare Forum -- identified values for all healthcare interactions and prioritized top values. The NAP group also prioritized top values for interprofessional interactions. Additional data was gathered via a Delphi process and 2 focus groups of Harvard Macy Institute scholars and faculty.Results: Through iterative content analyses and consensus, we identified 5 categories of core human values that should be present in every healthcare interaction: Capacity for Compassion, Respect for Persons, Commitment to Integrity and Ethical Practice, Commitment to Excellence, and Justice in Healthcare. Through further consensus and Delphi methodology, we identified values within each category.Conclusions: The International Charter for Human Values in Healthcare [1] is a cooperative effort to restore core human values to healthcare around the world. Major healthcare and education partners have joined this international effort. We are working to develop methods to translate the Charter’s universal values into education (teaching, assessment, curricula), research and practice.ReferenceThe International Charter for Human Values in Healthcare. http://charterforhealthcarevalues.or
The Role of a Psychiatrist (Rehabilitation Physician) in the Palliative Care Team
No full textObjective: Although palliative care consultation teams (PCTs) have become an integral part of all regional cancer care hospitals, cancer rehabilitation is still in the developing stage in Japan. At our hospital, a physiatrist, or a rehabilitation physician, joined the PCT as a member, and we have been achieving good results. The purpose of this study is to clarify the role of a physiatrist as a member of the PCT by investigating the current status of the PCT at our hospital.Method: We retrospectively analyzed the records of 144 patients receiving rehabilitation out of 345 patients who had started receiving PCT services from April 2012 to March 2013 at Keio University Hospital.Results: Among the 144 patients, 67 patients (46.5%) had already received rehabilitation before starting PCT services, and the remaining 77 patients (53.5%) started receiving rehabilitation based on the recommendation by the physiatrist. In the later group, Dietz Cancer Stage Classifications were: preventative, 6.5%; restorative, 40.0%; supportive, 45.5%; and palliative, 9.1%. ECOG-PS were: PS0, 0.0%; PS1, 23.4%; PS2, 29.9%; PS3, 28.6%; and PS4, 18.2%. The main purposes of rehabilitation were: 1) fracture prevention and pain relief of limbs with bone lesions, 2) social support (e.g. measures for the reduction of nursing requirement, assistance in finding social aids, counseling for family members), 3) psychological support, 4) treatment of lymphedema, 5) management of breathlessness, 6) and approaches to swallowing deficits.Conclusions: Half of the cancer patients started rehabilitation after the intervention by the PCT. Many patients receiving PCT services also needed rehabilitation services and the physiatrist had an important role of evaluating the rehabilitation needs. Physiatrists can act as important members of PCTs to maximize QOL while addressing the physical, psychological, social and spiritual needs of both patients and their families
Doctor, You Can Be Less Error Prone Right Now
No full textThe Problem:From moment to moment, while tending their patients, physicians can slip from: patience to impatience; genuine enquiry to assumptions; attention to the task-at-hand to inattention; certain doubt to doubtful certainty; and from doing what is inconvenient to doing what is convenient. In summary, one can slip from neo-cortex to archi-cortex (reptilian brain) emphasis. (The hazardous attitudes associated with aviation and medical mishaps are reptilian in character). This is expressed: to err is human, the reptilian part.Objectives: Therefore, to improve decisions, one needs to reclaim the new-brain emphasis, the advocate for the patient’s interests.Method: To be aware which emphasis one commands, ask oneself a few reptilian-revealing questions. Then counter the reptilian attitude by specific and or generic antidotes to be less error prone.Conclusion: Doctors should realize that there is also another patient one is tending: the patient called oneself, whose symptoms are haste, egoism and apathy and whose diagnosis is the reptilian brain. While this lesion is inoperable and the prognosis is guarded, yet amid the uncertainty and demands of our medical tending, one can toggle back to patience and doing the inconvenient to reach after fact and reason
Therapeutic Conversations with Seriously Ill People and Their Families
No full textSeriously ill people and those they love encounter health care professionals regularly. Published studies, representing how seriously ill people prefer to be communicated with suggest they would like open, honest and thoughtful communication. Additionally, these studies emphasize that seriously ill people prefer to talk about their illness when they are ready. Medical professionals are often on the frontline of communication with these people. There is a paucity of education on communicating with seriously ill people in professional education spanning many health care professions.Our workshop will empower participants in all capacities to better communicate with seriously ill people. We will teach not how to communicate information but rather how to have a therapeutic interaction that is consistent with what we know to be true about what seriously ill people value in their communication with their health care team.We will use patient narratives both oral and video, role play and reflection to convey an easy to implement framework to therapeutic communication.Session attendees will be able to1. Understand foundational communication desires of seriously ill people and their families.2. Describe a framework to approach difficult conversations with a therapeutic intention.3. Implement practical approaches to enhance their communication with seriously ill patients and families they encounter daily
Integral Medicine: Treating the Whole—Patient, Provider, Healthcare System
No full textPurpose: Integral Medicine is an approach to health, disease and healing that invites multiple perspectives and modes of inquiry to synergistically support healing for patients, providers and health care systems.Approach: Integral Theory is a framework for organizing information that considers four perspectives essential to view the whole patient simultaneously – any or all of which may illuminate health or illness in a patient, population or system: “Interior-Individual” (mind, psycho-spiritual development, etc.), “Exterior-Individual” (molecules, cells, organs, bodies, etc.), “Interior-Collective” (cultural, ethical practices or norms, etc.), and “Exterior-Collective” (socioeconomic, environmental system, etc.).Major Points: In practice, the application of Integral Theory to patient care can lead to four quadrant diagnosis and therapy for everything from status asthmaticus to chronic fatigue syndrome. When applied to the personal and professional development of providers an Integral Theory framework may improve critical thinking, ethical reasoning, mindfulness and empathy. At the healthcare system design level, patients have better outcomes when cared for by organizations ranked as having better work environments (where nurses report low rates of burnout, adequate time with patients, good relationships with colleagues, and opportunities for advanced training and continuing education).Conclusions: Treating the whole person becomes more than simply including body, mind and spirit. The whole person includes multiple epistemological ways of knowing. Building on Integrative, Alternative, Complementary, Evidence-based Medicine, and Values-based care, Integral Medicine offers a methodology for integrating the “best” of each of these medical methodologies. Integral Theory, in this respect, can act as a meta-theory weaving together many of the converging concepts emerging in the service of whole patient care. Integral methodology also provides a common map/language for knowledge integration/translation and a shared inter-professional approach to whole patient care at the patient, population and health system levels
Fostering Resilience over Multiple Losses for Nursing Staff in the Palliative Care Unit: Whole Person Approach – Part 2
No full textObjectives: “Bereavement overload” due to multiple losses is one of the stressors for the nursing staff working at Palliative Care Unit (PCU), which may be especially tough to those with less exposure to it. A support program was developed for the nursing staff of newly-opened PCU (April 2011) in order to foster resilience and wellness despite multiple losses. We conducted a study to evaluate the effectiveness of the support program with “whole person approach” – consisting of 3 modules: 1) lecture on grief and bereavement (mind), 2) experiential workshop on body awareness and relaxation (body/spirit), and 3) group discussion (mind/spirit), for the increased sense of self-efficacy, awareness of their inner healing power, and fostering mutual understanding and support.Methods: 20 nurses were randomly assigned to two groups for the action research project. Data included participant observation, individual and focus group interviews with one of the investigators. The support program package was offered from October to December 2012 (A) and from January to March 2013 (B) respectively, using wait-list control method. Self-efficacy scale was used at the base line, at the completion of package A, and at the completion of package B. Participants also answered brief survey after each module, followed by semi-structured interview.Results: The participants’ overall responses were positive, with comments like “becoming more aware of my own grief process” (module 1), “was amazed by the power of awareness and simple touch” (module 2), “inspired by learning others’ perspectives on death and dying” (module 3). Shared learning and reflection as well as “learning something tangible” seem to be important components of the program.Conclusions: The support program was positively received and contributed to the nursing staff’s increased sense of self-efficacy and resilience over “bereavement overload.” Continued program development is in progress based on the feedback
Clinical and Personal Value of Narrative Medicine Writing Workshops for Physicians and Practitioners
No full textObjectives: We write to tell our stories of patient encounters and come to understand them. A story discovers meaning in medicine. The objective is to write and tell stories of clinical encounters to develop self-awareness, patient perspectives and to demonstrate caring behaviors.Methods: One session takes 60 minutes (full exercise in poster). Longer sessions have multiple writing opportunities, longer small-table conversations, and a primer on developing character and setting in writing.Results: Over 8 years, in two conferences and 24 workshops (in 13 cities), 951 participants rated the sessions overall as 4.75 of 5, and 75% would use narrative in their practice. Also, 144 participants attended 20 writing groups. Selected Participant Comments:“Reminds me why we became doctors.”“Taking time to remember that each patient has an unfolding story is life affirming, however I found it startling to consider the doctor as part of the story.”“The training/sharing I had today will change how I view each patient interaction.”“Opened my eyes to how important my stories can be, and a new creative outlet.”“I know the people around my table better in two hours than I know the colleagues I work with everyday.”“I see this as a wellness mechanism! I am unlikely to meditate or go out for lunch during my busy day, but see myself able to close my office door and take 10 minutes to reflect upon a patient interaction in an attempt to find comfort or meaning there.”Conclusions: Offering a forum for physicians and practitioners to recall, write and share meaningful clinical moments has professional and personal value, as evidenced by the ratings and comments. Publishing the copyedited writings (with permission) in a medical journal, booklets, or a medical lit-art e-journal heightens the value, and allows others to share the experiences