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Translating theory into practice: Using Action Research to introduce a coordinated approach to emotional care
Patient Education and Counseling 73 (2008) 82–90 www.elsevier.com/locate/pateducou
Translating theory into practice: Using Action Research to introduce a coordinated approach to emotional care A.M. Williams a,b,c,*, S.S. Dawson a, L.J. Kristjanson a,b a
Curtin University of Technology, Perth, Western Australia, Australia b Edith Cowan University, Perth, Western Australia, Australia c St John of God Hospital Subiaco, Western Australia, Australia
Received 23 October 2007; received in revised form 11 April 2008; accepted 23 April 2008
Abstract Objective: This paper describes a translational project that explored the feasibility and effect of introducing a coordinated approach to emotional care. Methods: The project was undertaken using Action Research on one ward at St John of God Hospital Subiaco, Western Australia. A senior Registered Nurse was appointed to provide the leadership and direction to staff regarding emotional care and an education program for staff was provided. The project was evaluated using both quantitative and qualitative data. Results: Data demonstrated an increase in the patient’s evaluation of emotional care, although levels were found to fluctuate throughout the project. Factors such as the emotional distress of the staff were hypothesised as impacting on the delivery of emotional care. Conclusion: The approach used in this project was found to be a useful method of improving emotional care. However, the data collected in this study revealed the complexity of emotional care delivery and the possible impact of a number of factors within the environment. Practice implications: Emotional care delivery can be improved by using a coordinated research-based educational approach led by a clinical champion. However, the impact of other factors within the hospital environment needs to be considered and more research is required. # 2008 Elsevier Ireland Ltd. All rights reserved. Keywords: Caring; Communication; Action Research; Patients; Satisfaction; Translational Research
1. Introduction Action Research methodology was used to introduce a coordinated approach to improve the emotional care provided to hospitalised patients. The study focused on enhancing the interpersonal interactions of professional and non-professional staff working within one ward area of St John of God Hospital Subiaco. This is an acute care private hospital located in Perth, Western Australia. A clinical champion for emotional care was used, together with structured education interventions and evaluation methods. Hospitals are communities in which a number of people are employed to carry out different work which all contribute to the
* Corresponding author at: Western Australian Centre for Cancer and Palliative Care, Curtin University of Technology, Health Research Campus, PO Box U1987, Perth, Western Australia 6845, Australia. Tel.: +61 8 9346 3140; fax: +61 8 9346 4965. E-mail addresses: [email protected], [email protected] (A.M. Williams). 0738-3991/$ – see front matter # 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2008.04.011
functioning of the whole system. Chinn [1] cites the African proverb, ‘‘it takes a whole village to raise a child’’, and suggested that, likewise, a number of people can also contribute to the healing of a person. Chinn acknowledges the importance of certain relationships, but notes that a hospitalised patient receives care from a number of people who can all influence the quality of care received. Williams and Irurita [2] found that all of the people with whom a patient interacts during hospitalisation have the potential to influence their emotional status. Hence, this project was designed to enhance the interpersonal interactions of all staff with whom the patient has the potential to interact with during hospitalisation. During the 1990s five studies were undertaken in Western Australia that identified a reduction in the time available for nurse–patient interpersonal interactions, as well as a decreased focus on the psychosocial aspects of patient care. Factors influencing this decreased attention to emotional care included a shortage of nurses, reduced staffing numbers [3–5]; an increased focus on technical equipment [6], and a reliance of hospitals on casual and agency nurses [7]. Literature from the
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United Kingdom [8], Canada [9], and Norway [10] suggest the experience of similar difficulties in care provision. These factors have increased the workload of nurses, decreased the amount of time available for nurses to interact with patients, and reduced the opportunity for the development of relationships between nurses and patients. Apart from the discomfort experienced by patients when this aspect of care is diminished [6,4,5], nurses have also expressed dissatisfaction with their work when they are unable to provide the emotional care that they perceive patients need [5,11]. There may be implications on the satisfaction and retention of nurses related to their inability to provide emotional care to patients within the current healthcare environment. Hospitalisation and illness are often associated with stress and anxiety. Previous research has shown that physical symptoms are exacerbated in patients who experience excessive anxiety [12–14]. This anxiety can in some situations lead to more serious psychological disorders [15,16]. It is essential that strategies directed at the emotional care of patients are used within the clinical setting to minimise both psychological and physical distress. 1.1. A research-based framework for emotional care delivery This study used a research-based framework for emotional care delivery that was recently developed within Western Australia [17,2]. This framework is based on the premise that specific interpersonal interactions facilitate or contribute to the state of emotional comfort. This is a state that patients perceive to be therapeutic. Emotional comfort is associated with the feelings of a person and is defined as pleasant positive feelings, a state of relaxation [17,18]. Emotional care refers to the interpersonal interactions that facilitate or enhance the state of emotional comfort. This framework was translated in this project into a format that was readily understood by hospital staff [19]. A questionnaire to evaluate emotional care delivery from the perspective of patients was also developed from the original qualitative work and the psychometric properties of this instrument assessed as part of this project [20]. Patient satisfaction with care delivery in hospitals has been found to be associated with the quality of support provided to staff by nursing leaders [21]. Therefore, to enhance the interpersonal interactions of staff working within one area, a senior Registered Nurse was appointed to provide the leadership and the direction to focus on the emotional care of patients. The role of this nurse was to coordinate, educate and monitor the interactions of staff with patients. This nurse was also available to provide additional support to specific patients assessed in most need. 2. Methods 2.1. Aim The aim of this study was to explore the feasibility and effect of implementing a coordinated approach to emotional care in
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one ward area of St John of God Hospital Subiaco, Western Australia. The ward selected for the trial was an oncology ward. However, the intervention used was not disease specific and could have been used in other ward areas with patient populations other than persons with cancer. 2.2. Participants Participants included all staff who interacted with patients (professional, ancillary, and volunteers); and all patients admitted to a 31 bedded oncology ward during a 5-month period from April–August 2005. Ethical approval for the study was obtained from the both the hospital and the affiliated university. 2.3. Design Action Research was used in this feasibility study. When using this method, clinicians work in collaboration with researchers to find solutions to problems that relate to their particular setting [22]. Action Research and Participatory Action Research are research approaches which have been used for many years to facilitate change in varying contexts. Action Research differs from Participatory Action Research because the researcher is a person from outside the situation rather than within [23]. In this project the lead researcher did not work in the study ward, but had a nursing background and was sensitive to the experiences of the participants in the ward. Furthermore, a collaborative approach between clinicians and researchers was taken in the leadership of this project. Action Research is approached in phases. Five phases were used in this project: Planning, Preparing for Change, Implementing Change, Evaluating Change, and Adjusting Change. 2.3.1. Planning A multidisciplinary team of clinicians and researchers with an interest in the psychosocial care of hospitalised patients was convened and met regularly to develop and refine the resources for the project. 2.3.2. Preparing for change Expressions of interest were requested internally and a suitable person selected for the role of ‘‘Cancer Care Nurse’’ (CCN). There were three applicants for the position and two of these were interviewed. The selection criteria was a Registered Nurse with extensive experience working with patients within the cancer care setting, who had advanced interpersonal and written skills and the ability to prepare and deliver educational sessions. Enthusiasm for the project, self-motivation and a passion for enhancing the emotional care of patients were also factors which contributed to the selection of the CCN. These qualities in particular, were required for the role of a clinical champion. The person selected for the position was previously employed as a Registered Nurse on the proposed study ward. This nurse was prepared over several weeks before formally commencing in the role.
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Key persons within the ward were personally informed about the project and a newsletter outlining the project and introducing the newly appointed CCN was distributed to all staff. Two interactive educational workshops were developed using direct quotes from patients to illustrate the concepts being relayed. A 1 h workshop was designed for ancillary staff and volunteers; a 2 h version was designed for professional staff. The educational sessions commenced with an outline of the findings of the recent qualitative work that was carried out in Western Australia which had developed a substantive theory concerning the comfort of patients in hospital [17]. The sessions introduced the concept of emotional comfort and explained the effect of different environmental factors and needs of different patients. Staff were then encouraged to be aware of the needs of different patients and of their own behaviour and mood. Specific behaviours and interactions were then outlined using quotes from patients to highlight the impact of these interactions and behaviours on the emotional comfort of the patient. The specific behaviours and interactions were derived from the work of Williams and Irurita [2]. These were translated into common language with familiar examples by the CCN assigned to the project who was familiar with the ward culture. Several educational sessions were organised at times suitable to accommodate the majority of the staff. These workshops were presented to small groups of staff by the CCN and the Chief Investigator (AMW). A self-directed learning package was produced to supplement these workshops [19]. It was the intention of the project to include all staff working on the study ward in the educational sessions. However, although invited, only nurses attended the healthcare professional sessions. Other strategies were used to include other professions in the education such as the distribution of related articles and one-on-one discussions with the CCN. A separate, less detailed session was held for ancillary staff and volunteers and included Patient Care Assistants (who carried out multiple tasks in the ward area such as delivering meals, cleaning, and assisting with some aspects of patient care). 2.3.3. Implementing change The proposed changes to the emotional care of patients were implemented. The CCN coordinated the educational workshops which were attended by a total of 37 clinicians, thirty nurses and 11 ancillary staff and volunteers. This number represented 90% of the total staff on the ward (excluding allied health and medical staff). The CCN then commenced her role supporting patients identified in need of additional emotional care. 2.3.4. Evaluating change Both quantitative and qualitative methods were used to evaluate the changes in emotional care delivery that were implemented. Eleven bi-weekly surveys of inpatients were carried out using a questionnaire specifically developed and tested during the study. The questionnaire was named, ‘‘Patient Evaluation of Emotional Care during Hospitalisation’’ (PEECH) and was constructed using the same research-based framework as the educational program. Specific behaviours and
interactions, derived from the work of Williams and Irurita [2] as facilitating emotional comfort, were identified in the instrument. The changes in emotional care delivery anticipated as resulting directly from the educational sessions were evaluated by the patients currently experiencing care on the ward. The instrument was constructed as a Likert scale with 25 questions assessing the extent to which a particular interaction from any hospital staff member had been experienced. The PEECH contains three subscales of interactions which contribute to the emotional comfort of the patient. These subscales are: Level of Security, Level of Knowing and Level of Personal Value, and are extracted from previous qualitative work [17,2]. For each interaction the patients are asked to indicate using a tick in a box, whether they have experienced these positive interactions from all, most, some, or none of the staff during their admission. Face and content validity of the new instrument were assessed using an expert panel and a pilot test. Internal consistency reliability was assessed using Cronbach’s alpha coefficient. Two of the three subscales achieved an internal consistency estimate of at least 0.70. The internal structure of the tool was assessed using factor analysis and this confirmed the three subscales (a more detailed account of the development and testing of this instrument may be found in Williams and Kristjanson [20]). Qualitative data was collected through tape-recorded indepth interviews and feedback sessions. 2.3.5. Adjusting changes The coordinated approach to emotional care delivery was adjusted as the project progressed in light of the emerging findings. At the onset of the project it was acknowledged that the role of the CCN would evolve and develop as the project progressed. To ensure that the CCN was not overwhelmed with referrals in the initial phases of the project, the CCN only focussed on patients from two of the oncology consultants. The CCN took patient referrals directly from each consultant. In addition to this, the CCN contacted all new patients who were going to be receiving chemotherapy, radiotherapy, and other cancer related treatments including surgery. The CCN provided new patients with information and the opportunity to discuss treatment and any anxieties. To aid in the provision of information to patients, the CCN developed a ‘‘Patient Information Folder’’ designed to be given to all new patients. To enhance the identification of emotional issues and concerns for patients, and to implement specific emotional care, the CCN established weekly multidisciplinary meetings. The aim of these meetings was to provide a framework that facilitated communication between staff and to ensure a comprehensive and ongoing assessment and evaluation of inpatients needs, with appropriate referrals. These meetings raised the awareness of all members of the multidisciplinary team about emotional issues related to specific patients. As part of the preparation for the role of the CCN, information about the roles and responsibilities of all members of the multidisciplinary team providing cancer services was collated by
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the CCN. This information was developed into a wall chart which profiled each service. This included information such as suitability for patients, times available, fees, function, and the referral process. This wall chart was placed in a prominent area of the ward for easy reference by staff. A coordinator for volunteers was appointed about the same time as the CCN. The availability and access to volunteers was greatly improved by this position. The CCN promoted the use of volunteers as an option for staff to consider as an additional source of emotional care. At the conclusion of the project, the role of the CCN was made permanent and the scope of the role was widened to include cancer patients located in other parts of the hospital. A second CCN was also employed and a new name was given to the position. The two ‘‘Clinical Nurse Consultants for Cancer’’ currently separate their work by focussing on patients with specific cancers.
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Fig. 1. Percentage of level of security interactions experienced by patients (questions 1–19).
2.4. Data analysis 2.4.1. Quantitative Quantitative data from the PEECH questionnaire were analysed using the Statistical Package for the Social Sciences version 11.5. Descriptive statistics were produced evaluating the percentage of patient responses to each of the three subscales included in the instrument. Graphs showing these responses were developed for each survey and displayed in the ward area. The psychometric properties of the PEECH were determined firstly using Cronbach’s alpha to assess the internal consistency reliability, and secondly using exploratory factor analysis to examine the internal structure of the instrument. Encouraging results were obtained during this testing and these are described elsewhere [20]. 2.4.2. Qualitative Interviews with patients and staff were transcribed verbatim from tape recordings, and data were analysed using content analysis and constant comparative techniques [24]. Theoretical sampling was used, allowing the emerging findings to direct subsequent data collection. The QSR qualitative data computer program [25] was used to manage the data. Major themes and categories relating to the changes that were implemented were identified. Feedback concerning the emerging themes was given to the staff on the participating ward.
Fig. 2. Percentage of level of knowing interactions experienced by patients (questions 1–19).
was undertaken the week immediately following the completion of the educational workshops. Figs. 1–3 show the percentage of responses for questions 1–19 for the baseline survey and survey 1. An immediate improvement in each of the subscales was observed with the greatest changes noticeable in the Level of Security and Level of Personal Value. Survey 4, 5 and 6 continued to show an increase and maintenance above the baseline levels in each of the subscales of emotional care. However, when survey 7 was performed a dramatic decrease in all of the subscale levels was observed. An investigation into the reasons behind this decrease revealed that during the previous week 6 patients had died and staff on the ward were feeling emotionally distressed themselves. As the surveys continued it became apparent that the PEECH was sensitive to the changing environment of the ward. The resignation of several nurses during the project led to a shortage of permanent staff. The implications of this were a greater reliance on agency staff and a perception of decreased time for patient care, especially emotional care. Survey 9 showed another decrease in patients’ evaluation of emotional care. The comments provided by patients during this survey
3. Results 3.1. Quantitative evaluation One hundred and forty-six patients from the study ward were surveyed during the project. In addition, a further 132 patients across the hospital completed the questionnaire to further appraise its psychometric qualities. A total of eleven surveys of patients in the study ward were undertaken. A baseline survey took place before the changes were introduced and the ward was then surveyed every 2 weeks for 5 months. The first survey
Fig. 3. Percentage of level of personal value experienced by patients (questions 1–19).
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Fig. 4. Percentage of best response (all) for each subscale on range of surveys (questions 1–19).
confirmed that patients were aware that time for emotional care was sometimes limited. For example: ‘‘Sometimes the response to a call is slow. There may be a shortage of staff’’ (Patient, Survey 9). ‘‘Great group of people. Appears difficult to cover all aspects of care with amount of people and care required’’ (Patient, Survey 9). ‘‘The only comment I can make is the staff are the greatest. There should be more night staff. There are only a few and a lot of patients. I feel sorry for the night staff’’ (Patient, Survey 9). Although there was a fall in levels of emotional care at certain times during the project, when the final two surveys were performed, high levels of emotional care in all three subscales were again observed (see Fig. 4). While the research project was in progress the annual hospital satisfaction measurement was performed using the Press Ganey Inpatient Satisfaction Survey [26], which had been used in the hospital since 2003. It was noted that the overall rating for the study ward was significantly higher in 2005 than in 2004. An increase in the mean score was reported from 80.7 in 2003 to 86.7 in 2005 ( p < 0.05). This score was also significantly higher than the mean score for the entire hospital. The study ward also scored significantly higher means for 20 individual items out of a total of 38 items. Not all of these items relate to interpersonal interactions, but of special note is the subscale relating to nursing care where 7 out of 8 items were significantly higher than the mean scores for the rest of the hospital. The only item in this section that was not statistically significant related to the promptness of responses to call, but even this improved 4.1 points since the previous survey in 2004 demonstrating an improved trend.
3.2. Qualitative evaluation In-depth interviews with 10 staff were carried out. Eight of these participants were female and two were male. Ages ranged from 21 to 58 years. Five months was the shortest length of time working on the ward and seven years was the longest. Six staff who attended feedback sessions also provided qualitative data which was obtained through detailed notes of their comments regarding their experiences participating in the study. Qualitative data from patients was collected through two indepth interviews with patients, as well as from comments recorded on the PEECH instrument. The qualitative evaluation revealed a number of barriers perceived by staff to prevent the provision of emotional care to patients. Even though there was an overall desire by the staff members who were interviewed to provide emotional care to patients and their families, they often did not always feel able to do this. The reasons for this were identified as: inadequate staffing; ward organisation, routine and culture; lack of privacy; and emotionally distressed staff. Qualitative data provided a greater insight into the results from the PEECH questionnaire. When staff felt that they had been unable to provide emotional care to patients they felt frustrated, concerned, and guilty: . . . you just feel at the end of the day, you feel like you haven’t given them everything that you could because you didn’t have the time and that makes you quite angry. It’s quite frustrating thinking they wouldn’t be so upset if I only had the time to sit down and listen to them. But you don’t because while you’re in there delivering that care, you’ve got bells on, people calling your name, wanting this, needing that (Staff member). The staff who were interviewed said that the introduction of the CCN role eased some of the emotional distress that they
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experienced. This was because, in situations where they felt they were unable to provide the emotional care that they perceived was needed, someone else was available to address this: I think it’s wonderful to have somebody who can provide the missing link . . . it’s a great consolation to know there’s somebody that you can fall back onto, bring into a situation where you’re feeling you’re not doing enough for your patient in that area of coping emotionally with what they’re going through (Staff member). The staff members who were interviewed discussed their experiences with death and reported the need for time after a patient had died, to care for families and themselves. They often developed attachments to specific patients and experienced a deep sense of loss when these patients died, ‘‘. . . people kind of forget that we’re also upset’’ (Staff member). 4. Discussion and conclusion 4.1. Discussion The coordinated approach to emotional care delivery used in this project appeared to be an effective way to increase the emotional comfort and satisfaction experienced by patients on an oncology ward. The use of an Action Research design facilitated the introduction of changes in emotional care, whilst providing insight into the factors that facilitate and hinder emotional care delivery in the clinical setting. Action Research is particularly suited for this type of project because it reveals the reality of a particular situation by the inclusion of the participants in the research process. The manner of this inclusion and contribution is credited with the facilitation of change that is more readily accepted as relevant [27]. The CCN role introduced in this project was found to provide the momentum and leadership necessary for the changes to be incorporated into the everyday practice of all working on the project ward. DeBourgh [28] described the use of an advanced practice nurse for being ideally suited as a ‘‘Champion’’ for change. In a literature review to clarify the concepts in knowledge transfer, Thompson et al. [29] found the role of a facilitator for change to be an useful tool that was described as ‘‘dynamic and active’’ (p. 694). The literature reviewed by these authors found that successful facilitators of change possessed effective interpersonal and communication skills and were able to create a learning environment for change that supported the needs of all those involved with change process. The introduction of a new role of CCN in this study also provided an additional source of emotional care for those patients considered most distressed. Roberts et al. [30] described a similar role of generalist CCN in Melbourne and observed that the use of such roles was not common within Australia. In that study, the role of two nurses was evaluated using a structured telephone interview with 98 patients. Overall, patients were very satisfied with the service, ‘‘Patients reported that they felt more supported and positive, better able
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to cope, less worried and more in control’’ (p. 53). Strong et al. [31] described a pilot study where oncology nurses were trained to screen cancer patients for depression. Although this strategy was assessed as having merit, caution was suggested in such roles with regard to the excessive emotional demands placed on the nurse. A comparable role of CCN is that of specialist breast care nurse and this role has been widely reported in the literature. The use of specialist breast cancer nurses would appear to be a more common occurrence in hospitals than generalist CCNs. Within Australia, Liebert and Furber [32] evaluated the care received by 240 women in New South Wales and found high levels of satisfaction with this role which provided important information and emotional support to women at key points in their treatment. In another study of 63 women who had breast cancer in New South Wales, a survey revealed further support for the role of specialist breast care nurse [33]. However, evaluation of the role of generalist CCN was limited in this current study and further quantitative measurement of the outcomes associated with such a role is warranted. The research-based framework of emotional care introduced in the education and evaluation of this project was readily understood and embraced by the staff who participated in this project. The educational workshops enabled staff to be more purposeful in their emotional care delivery. The use of direct quotes from patients used in the emotional care workshops were said to be extremely powerful and helped staff to gain insight into the world of hospitalised patients. A variety of educational courses have been used in different parts of the world to equip healthcare professional with effective communication skills to provide emotional care for patients. The content of these courses vary and some include novel approaches such as using simulated patients, role-play [34], nominal group techniques [35], and clinical supervision [36] to promote learning. A systematic review of communication skills training for health care professionals working in the field of cancer [37] noted the positive effects of this type of training. However, the outcomes have tended to be measured from the skills level of the participant, rather than from the experience of the participant of care, the patient, as was the case in this current study. Another Australian study which evaluated health professional communication from the perspective of patients was carried out by Trumble et al. [38]. In this study a 3-h communication skills training workshop for doctors was evaluated. Thirty patients of 174 doctors were then asked to evaluate their experience of their doctors’ communication 1 week before the workshop and 3 months afterwards. Statistically significant improvements ( p 0.01) were noted in each of the 10 aspects of communication evaluated. Communication programs for health care professionals have more often been discussed in the literature as part of an undergraduate or postgraduate degree [39,40], than within the hospital setting, as in this current study. Another study which aimed to improve the communication skills of hospital staff took place in China [41] and used a quasi-experimental design to evaluate an integrated communication skills training
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program for 129 nurses in a cancer hospital. The program consisted of a 3-day course followed up by peer support groups at a ward level, managerial support and the provision of a handbook containing further training resources. Statistically significant improvements for all outcomes were recorded for the nurses in the experimental group compared to the control group at 1 and 6 months after training. An integral part of the coordinated approach to emotional care used in this project was the inclusion of ancillary hospital staff and volunteers in the educational program. A review of the literature did not identify any other initiatives within hospitals that had acknowledged the important role that these workers have in terms of emotional care, or provided education to enhance and promote these skills. During this project it was noted that the quality of emotional care delivered to patients was diminished when staff themselves were feeling emotionally distressed. Part of this distress appeared to be related to staff perceiving that it was not always possible to take the time that was needed to provide the emotional care that they felt was needed by patients with cancer. It was hypothesised that the quality of emotional care delivered was diminished when staff themselves were feeling emotionally distressed. This finding would need to be explored further in subsequent work. Similar findings were found in a previous grounded theory study by Williams [5]. In that study nurses working in other setting apart from cancer care, were found to prioritise physical care over emotional care because of a lack of time. A recent survey of nurses working in the United Kingdom (UK) found that the majority (64.6%) believed that they did not have enough time to do their work. This survey also found that 51.9% reported that they could only provide emotional care to patients some of the time [8]. Emotional exhaustion and an intention to leave their current job have been found to be more likely to occur in nurses who worked in environments where a high patient ratio was common [11]. A number of different factors in the work environment of oncology nurses have been reported as being stressful in another study of oncology nurses in Brazil. Factors such as the suffering of patients, not having enough time or physical resources, concern about making errors, and perceiving a lack of support from management, achieved the highest scores in terms of associated stress [42]. Despite the perception by staff that there were times when insufficient time was available for them to provide emotional care to patients, the patients participating in the survey conducted in this study generally reported that the staff on the project ward provided high levels of emotional care. Williams [5] found nurses used a process of ‘‘selective focussing’’ whereby selective patients were given high quality physical and emotional care. High quality care provision was only possible by compromising the care of some patients. A process of ‘‘balancing and compromising’’ was identified by Irurita and Williams [43] as being used by both patients and nurses to preserve each others’ integrity within an environment of limited resources. The use of such processes would explain why high levels of emotional care provision were reported by some
patients, despite the adverse circumstances identified by staff members. 4.2. Conclusion The translation of theory into practice is not an easy task. This paper has described the successful translation of a research-based theory of emotional care into the clinical practice of a ward at St John of God Hospital Subiaco, which cared for patients with cancer. The use of the Action Research method and a clinical champion for emotional care were key elements which led to the success of this project. The new role of a generalist CCN introduced in this project was viewed positively by both patients and staff and appraised as a valuable resource. The hospital-based educational program developed in this project was found to be a useful method of increasing staff’s awareness of the emotional care needs of different patients by providing simple, practical strategies that both professional and non-professional staff could use to contribute to the emotional care of patients. The collaborative partnership between the clinicians and the researchers in this project enhanced the development of this education. The ongoing evaluation of the coordinated approach to emotional care introduced in this project using the PEECH instrument to measure the outcomes from the perspective of the patients, as well as the qualitative data, provided a valuable insight into the factors that facilitate and hinder emotional care provision. A relationship between the quality of emotional care delivery and the emotional wellbeing of staff was hypothesised in this project. This finding supports previous work that has identified factors such as a lack of time, related to staffing issues, as impacting on the delivery of emotional care. It is likely that extended periods of work in such conditions could have a detrimental impact on the wellbeing of the staff, and their ability to deliver quality emotional care. In addition to this, taking into account the nature of the work on the project ward, as well as the large numbers of patient deaths that regularly occurred there, programs of stress management, and avenues for debriefing for hospital staff are likely to be beneficial. Such strategies would help to preserve the emotional integrity of the staff, and may improve their abilities to provide quality emotional care and retention rates. Initiative to address this have already commenced at the study hospital. It is critical that impact of environmental factors on the wellbeing of staff is considered and addressed as part of any program that is directed at improving the emotional care delivered to patients. 4.3. Practice implications Consider use of the Action Research method in combination with a clinical champion when introducing change into the clinical setting. The generalist Cancer Care Nurse role offers an additional source of support for emotionally distressed patients. Further investigation into the outcomes associated with the role of the generalist Cancer Care Nurse.
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Emotional care for hospitalised patients may be improved by using a coordinated educational approach for staff, including ancillary staff and volunteers. Further investigation into the relationship between the emotional wellbeing of hospital staff and emotional care delivery is warranted.
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Acknowledgements
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This research was funded by the National Health and Medical Research Council Grant ID 274906 and an Industry Collaboration Grant from Edith Cowan University and St John of God Hospital Subiaco. We gratefully acknowledge the following for their support and contribution to this project: patients and staff participants; supporting staff at St John of God Hospital Subiaco: Danielle Darragh, Vivienne Garrick, Chris Hanna, Joan Jessup, Michaela Kilroy, Dr. Siobhan Ng, Dr. David Ransom, Sue Terry, and the Psychosocial Care Committee at St John of God Hospital Subiaco: Michael Brennan, Vicki Brown, Valerie Colgan, Anne Fox, Jennifer Gardner, Rita Paglia, Deborah Pearson, and Julie Teraci. As well, the assistance of Rebecca Osseiran-Moisson, Aurora Popescu, Therese Shaw and Sandra Pereira in the statistical analysis aspects of this project was appreciated.
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logical distress in patients undergoing radical cystectomy for bladder cancer. J Urol 2004;172:1814–7. Strong V, Sharpe M, Cull A, Maguire P, House A, Ramivez A. Can oncology nurses treat depression? A pilot project. J Adv Nurs 2004;46: 542–8. Williams AM. The contribution of therapeutic interpersonal interactions to the comfort of hospitalised patients. A grounded theory study of the patient’s perspective. Unpublished doctoral dissertation. Perth, WA: Curtin University of Technology; 2003. Williams AM, Irurita VF. Emotional comfort: the patient’s perspective of a therapeutic context. Int J Nurs Stud 2006;43:405–15. Williams AM, Mundy M. Emotional care from the patient’s perspective: a self-directed learning package for all caregivers. St John of God Hospital, Subiaco & the Western Australian Centre for Cancer and Palliative Care, Edith Cowan University, Churchlands, Western Australia; 2005. Williams AM, Kristjanson LJ. The development and testing of an instrument to measure the emotional care experienced by hospitalised patients. J Clin Nurs; in press. Aiken LH, Slone DM, Lake ET. Satisfaction with inpatient acquired immunodeficiency syndrome care: a national comparison of dedicated and scattered-bed units. Med Care 1997;35:948–62. Streubert HJ, Carpenter DR. Qualitative research in nursing. Philadelphia: Lippincott; 1999. Corbett AM, Francis K, Chapman Y. Feminist-informed participatory action research: a methodology of choice for examining critical nursing issues. Int J Nurs Pract 2007;13:81–8. Glaser BG, Strauss A. The discovery of grounded theory: strategies for qualitative research. London: Weidenfeld & Nicolson; 1967. QRS N6 [Computer software]. Melbourne, Australia: QSR International Pty. Ltd; 2002. Press Ganey Associates Inc. Inpatient patient satisfaction survey. South Bend, IN; 2005. Greenwood J. Action research and action researchers: some introductory considerations. Contemp Nurse 1994;3:84–92. DeBourgh GA. Champions for evidence-based practice: a critical role for advanced practice nurses. AACN Advanced Critical Care 2001;12:491–508. Thompson GN, Estabrooks CA, Degner LF. Clarifying the concepts in knowledge transfer: a literature review. J Adv Nurs 2006;53:691–701. Roberts S, Schofield P, Freeman J, Hill D, Akkerman D, Roger A. Bridging the information and support gap: evaluation of a hospital-based cancer support nurse service. Patient Educ Couns 2002;47:47–55. Strong V, Sharpe M, Cull A, Maguire P, House A, Ramirez A. Can oncology nurses treat depression? A pilot project. J Adv Nurs 2004;46:542–8. Liebert B, Furber S. Australian women’s perceptions of a specialist breast nurse model. Aust Health Rev 2004;27:88–93. Szwajcer A, Hannan R, Donoghue J, Mitten-Lewis S. Evaluating key dimensions of the breast care nurse role in Australia. Cancer Nurs 2004;27:79–84. Lane C, Rollnick S. The use of simulated patients and role-play in communication skills training: a review of the literature to August 2005. Patient Educ Couns 2007;67:13–20. Perry J, Linsley S. The use of the nominal group technique as an evaluative tool in the teaching and summative assessment of the interpersonal skills of student mental health nurses. Nurse Educ Today 2006;26:346–53. Heaven C, Clegg J, Maguire P. Transfer of communication skills training from workshop to workplace: the impact of clinical supervision. Patient Educ Couns 2006;60:313–25. Fellowes D, Wilkinson S, Moore P. Communication skills training for health care professionals working with cancer patients, their families and/ or carers. Cochrane Database Syst Rev 2004 [Art. No.: CD003751. doi:10.1002/14651858.CD003751.pub2]. Trumble SC, O’Brien ML, O’Brien M, Hartwig B. Communication skills training for doctors increases patient satisfaction. Clin Governance Int J 2006;11:299–307. Cegala DJ, Broz SL. Physician communication skills training: a review of theoretical backgrounds, objectives and skills. Med Educ 2002;36:1004– 16.
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Translating theory into practice: Using Action Research to introduce a coordinated approach to emotional care A.M. Williams a,b,c,*, S.S. Dawson a, L.J. Kristjanson a,b a
Curtin University of Technology, Perth, Western Australia, Australia b Edith Cowan University, Perth, Western Australia, Australia c St John of God Hospital Subiaco, Western Australia, Australia
Received 23 October 2007; received in revised form 11 April 2008; accepted 23 April 2008
Abstract Objective: This paper describes a translational project that explored the feasibility and effect of introducing a coordinated approach to emotional care. Methods: The project was undertaken using Action Research on one ward at St John of God Hospital Subiaco, Western Australia. A senior Registered Nurse was appointed to provide the leadership and direction to staff regarding emotional care and an education program for staff was provided. The project was evaluated using both quantitative and qualitative data. Results: Data demonstrated an increase in the patient’s evaluation of emotional care, although levels were found to fluctuate throughout the project. Factors such as the emotional distress of the staff were hypothesised as impacting on the delivery of emotional care. Conclusion: The approach used in this project was found to be a useful method of improving emotional care. However, the data collected in this study revealed the complexity of emotional care delivery and the possible impact of a number of factors within the environment. Practice implications: Emotional care delivery can be improved by using a coordinated research-based educational approach led by a clinical champion. However, the impact of other factors within the hospital environment needs to be considered and more research is required. # 2008 Elsevier Ireland Ltd. All rights reserved. Keywords: Caring; Communication; Action Research; Patients; Satisfaction; Translational Research
1. Introduction Action Research methodology was used to introduce a coordinated approach to improve the emotional care provided to hospitalised patients. The study focused on enhancing the interpersonal interactions of professional and non-professional staff working within one ward area of St John of God Hospital Subiaco. This is an acute care private hospital located in Perth, Western Australia. A clinical champion for emotional care was used, together with structured education interventions and evaluation methods. Hospitals are communities in which a number of people are employed to carry out different work which all contribute to the
* Corresponding author at: Western Australian Centre for Cancer and Palliative Care, Curtin University of Technology, Health Research Campus, PO Box U1987, Perth, Western Australia 6845, Australia. Tel.: +61 8 9346 3140; fax: +61 8 9346 4965. E-mail addresses: [email protected], [email protected] (A.M. Williams). 0738-3991/$ – see front matter # 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2008.04.011
functioning of the whole system. Chinn [1] cites the African proverb, ‘‘it takes a whole village to raise a child’’, and suggested that, likewise, a number of people can also contribute to the healing of a person. Chinn acknowledges the importance of certain relationships, but notes that a hospitalised patient receives care from a number of people who can all influence the quality of care received. Williams and Irurita [2] found that all of the people with whom a patient interacts during hospitalisation have the potential to influence their emotional status. Hence, this project was designed to enhance the interpersonal interactions of all staff with whom the patient has the potential to interact with during hospitalisation. During the 1990s five studies were undertaken in Western Australia that identified a reduction in the time available for nurse–patient interpersonal interactions, as well as a decreased focus on the psychosocial aspects of patient care. Factors influencing this decreased attention to emotional care included a shortage of nurses, reduced staffing numbers [3–5]; an increased focus on technical equipment [6], and a reliance of hospitals on casual and agency nurses [7]. Literature from the
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United Kingdom [8], Canada [9], and Norway [10] suggest the experience of similar difficulties in care provision. These factors have increased the workload of nurses, decreased the amount of time available for nurses to interact with patients, and reduced the opportunity for the development of relationships between nurses and patients. Apart from the discomfort experienced by patients when this aspect of care is diminished [6,4,5], nurses have also expressed dissatisfaction with their work when they are unable to provide the emotional care that they perceive patients need [5,11]. There may be implications on the satisfaction and retention of nurses related to their inability to provide emotional care to patients within the current healthcare environment. Hospitalisation and illness are often associated with stress and anxiety. Previous research has shown that physical symptoms are exacerbated in patients who experience excessive anxiety [12–14]. This anxiety can in some situations lead to more serious psychological disorders [15,16]. It is essential that strategies directed at the emotional care of patients are used within the clinical setting to minimise both psychological and physical distress. 1.1. A research-based framework for emotional care delivery This study used a research-based framework for emotional care delivery that was recently developed within Western Australia [17,2]. This framework is based on the premise that specific interpersonal interactions facilitate or contribute to the state of emotional comfort. This is a state that patients perceive to be therapeutic. Emotional comfort is associated with the feelings of a person and is defined as pleasant positive feelings, a state of relaxation [17,18]. Emotional care refers to the interpersonal interactions that facilitate or enhance the state of emotional comfort. This framework was translated in this project into a format that was readily understood by hospital staff [19]. A questionnaire to evaluate emotional care delivery from the perspective of patients was also developed from the original qualitative work and the psychometric properties of this instrument assessed as part of this project [20]. Patient satisfaction with care delivery in hospitals has been found to be associated with the quality of support provided to staff by nursing leaders [21]. Therefore, to enhance the interpersonal interactions of staff working within one area, a senior Registered Nurse was appointed to provide the leadership and the direction to focus on the emotional care of patients. The role of this nurse was to coordinate, educate and monitor the interactions of staff with patients. This nurse was also available to provide additional support to specific patients assessed in most need. 2. Methods 2.1. Aim The aim of this study was to explore the feasibility and effect of implementing a coordinated approach to emotional care in
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one ward area of St John of God Hospital Subiaco, Western Australia. The ward selected for the trial was an oncology ward. However, the intervention used was not disease specific and could have been used in other ward areas with patient populations other than persons with cancer. 2.2. Participants Participants included all staff who interacted with patients (professional, ancillary, and volunteers); and all patients admitted to a 31 bedded oncology ward during a 5-month period from April–August 2005. Ethical approval for the study was obtained from the both the hospital and the affiliated university. 2.3. Design Action Research was used in this feasibility study. When using this method, clinicians work in collaboration with researchers to find solutions to problems that relate to their particular setting [22]. Action Research and Participatory Action Research are research approaches which have been used for many years to facilitate change in varying contexts. Action Research differs from Participatory Action Research because the researcher is a person from outside the situation rather than within [23]. In this project the lead researcher did not work in the study ward, but had a nursing background and was sensitive to the experiences of the participants in the ward. Furthermore, a collaborative approach between clinicians and researchers was taken in the leadership of this project. Action Research is approached in phases. Five phases were used in this project: Planning, Preparing for Change, Implementing Change, Evaluating Change, and Adjusting Change. 2.3.1. Planning A multidisciplinary team of clinicians and researchers with an interest in the psychosocial care of hospitalised patients was convened and met regularly to develop and refine the resources for the project. 2.3.2. Preparing for change Expressions of interest were requested internally and a suitable person selected for the role of ‘‘Cancer Care Nurse’’ (CCN). There were three applicants for the position and two of these were interviewed. The selection criteria was a Registered Nurse with extensive experience working with patients within the cancer care setting, who had advanced interpersonal and written skills and the ability to prepare and deliver educational sessions. Enthusiasm for the project, self-motivation and a passion for enhancing the emotional care of patients were also factors which contributed to the selection of the CCN. These qualities in particular, were required for the role of a clinical champion. The person selected for the position was previously employed as a Registered Nurse on the proposed study ward. This nurse was prepared over several weeks before formally commencing in the role.
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Key persons within the ward were personally informed about the project and a newsletter outlining the project and introducing the newly appointed CCN was distributed to all staff. Two interactive educational workshops were developed using direct quotes from patients to illustrate the concepts being relayed. A 1 h workshop was designed for ancillary staff and volunteers; a 2 h version was designed for professional staff. The educational sessions commenced with an outline of the findings of the recent qualitative work that was carried out in Western Australia which had developed a substantive theory concerning the comfort of patients in hospital [17]. The sessions introduced the concept of emotional comfort and explained the effect of different environmental factors and needs of different patients. Staff were then encouraged to be aware of the needs of different patients and of their own behaviour and mood. Specific behaviours and interactions were then outlined using quotes from patients to highlight the impact of these interactions and behaviours on the emotional comfort of the patient. The specific behaviours and interactions were derived from the work of Williams and Irurita [2]. These were translated into common language with familiar examples by the CCN assigned to the project who was familiar with the ward culture. Several educational sessions were organised at times suitable to accommodate the majority of the staff. These workshops were presented to small groups of staff by the CCN and the Chief Investigator (AMW). A self-directed learning package was produced to supplement these workshops [19]. It was the intention of the project to include all staff working on the study ward in the educational sessions. However, although invited, only nurses attended the healthcare professional sessions. Other strategies were used to include other professions in the education such as the distribution of related articles and one-on-one discussions with the CCN. A separate, less detailed session was held for ancillary staff and volunteers and included Patient Care Assistants (who carried out multiple tasks in the ward area such as delivering meals, cleaning, and assisting with some aspects of patient care). 2.3.3. Implementing change The proposed changes to the emotional care of patients were implemented. The CCN coordinated the educational workshops which were attended by a total of 37 clinicians, thirty nurses and 11 ancillary staff and volunteers. This number represented 90% of the total staff on the ward (excluding allied health and medical staff). The CCN then commenced her role supporting patients identified in need of additional emotional care. 2.3.4. Evaluating change Both quantitative and qualitative methods were used to evaluate the changes in emotional care delivery that were implemented. Eleven bi-weekly surveys of inpatients were carried out using a questionnaire specifically developed and tested during the study. The questionnaire was named, ‘‘Patient Evaluation of Emotional Care during Hospitalisation’’ (PEECH) and was constructed using the same research-based framework as the educational program. Specific behaviours and
interactions, derived from the work of Williams and Irurita [2] as facilitating emotional comfort, were identified in the instrument. The changes in emotional care delivery anticipated as resulting directly from the educational sessions were evaluated by the patients currently experiencing care on the ward. The instrument was constructed as a Likert scale with 25 questions assessing the extent to which a particular interaction from any hospital staff member had been experienced. The PEECH contains three subscales of interactions which contribute to the emotional comfort of the patient. These subscales are: Level of Security, Level of Knowing and Level of Personal Value, and are extracted from previous qualitative work [17,2]. For each interaction the patients are asked to indicate using a tick in a box, whether they have experienced these positive interactions from all, most, some, or none of the staff during their admission. Face and content validity of the new instrument were assessed using an expert panel and a pilot test. Internal consistency reliability was assessed using Cronbach’s alpha coefficient. Two of the three subscales achieved an internal consistency estimate of at least 0.70. The internal structure of the tool was assessed using factor analysis and this confirmed the three subscales (a more detailed account of the development and testing of this instrument may be found in Williams and Kristjanson [20]). Qualitative data was collected through tape-recorded indepth interviews and feedback sessions. 2.3.5. Adjusting changes The coordinated approach to emotional care delivery was adjusted as the project progressed in light of the emerging findings. At the onset of the project it was acknowledged that the role of the CCN would evolve and develop as the project progressed. To ensure that the CCN was not overwhelmed with referrals in the initial phases of the project, the CCN only focussed on patients from two of the oncology consultants. The CCN took patient referrals directly from each consultant. In addition to this, the CCN contacted all new patients who were going to be receiving chemotherapy, radiotherapy, and other cancer related treatments including surgery. The CCN provided new patients with information and the opportunity to discuss treatment and any anxieties. To aid in the provision of information to patients, the CCN developed a ‘‘Patient Information Folder’’ designed to be given to all new patients. To enhance the identification of emotional issues and concerns for patients, and to implement specific emotional care, the CCN established weekly multidisciplinary meetings. The aim of these meetings was to provide a framework that facilitated communication between staff and to ensure a comprehensive and ongoing assessment and evaluation of inpatients needs, with appropriate referrals. These meetings raised the awareness of all members of the multidisciplinary team about emotional issues related to specific patients. As part of the preparation for the role of the CCN, information about the roles and responsibilities of all members of the multidisciplinary team providing cancer services was collated by
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the CCN. This information was developed into a wall chart which profiled each service. This included information such as suitability for patients, times available, fees, function, and the referral process. This wall chart was placed in a prominent area of the ward for easy reference by staff. A coordinator for volunteers was appointed about the same time as the CCN. The availability and access to volunteers was greatly improved by this position. The CCN promoted the use of volunteers as an option for staff to consider as an additional source of emotional care. At the conclusion of the project, the role of the CCN was made permanent and the scope of the role was widened to include cancer patients located in other parts of the hospital. A second CCN was also employed and a new name was given to the position. The two ‘‘Clinical Nurse Consultants for Cancer’’ currently separate their work by focussing on patients with specific cancers.
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Fig. 1. Percentage of level of security interactions experienced by patients (questions 1–19).
2.4. Data analysis 2.4.1. Quantitative Quantitative data from the PEECH questionnaire were analysed using the Statistical Package for the Social Sciences version 11.5. Descriptive statistics were produced evaluating the percentage of patient responses to each of the three subscales included in the instrument. Graphs showing these responses were developed for each survey and displayed in the ward area. The psychometric properties of the PEECH were determined firstly using Cronbach’s alpha to assess the internal consistency reliability, and secondly using exploratory factor analysis to examine the internal structure of the instrument. Encouraging results were obtained during this testing and these are described elsewhere [20]. 2.4.2. Qualitative Interviews with patients and staff were transcribed verbatim from tape recordings, and data were analysed using content analysis and constant comparative techniques [24]. Theoretical sampling was used, allowing the emerging findings to direct subsequent data collection. The QSR qualitative data computer program [25] was used to manage the data. Major themes and categories relating to the changes that were implemented were identified. Feedback concerning the emerging themes was given to the staff on the participating ward.
Fig. 2. Percentage of level of knowing interactions experienced by patients (questions 1–19).
was undertaken the week immediately following the completion of the educational workshops. Figs. 1–3 show the percentage of responses for questions 1–19 for the baseline survey and survey 1. An immediate improvement in each of the subscales was observed with the greatest changes noticeable in the Level of Security and Level of Personal Value. Survey 4, 5 and 6 continued to show an increase and maintenance above the baseline levels in each of the subscales of emotional care. However, when survey 7 was performed a dramatic decrease in all of the subscale levels was observed. An investigation into the reasons behind this decrease revealed that during the previous week 6 patients had died and staff on the ward were feeling emotionally distressed themselves. As the surveys continued it became apparent that the PEECH was sensitive to the changing environment of the ward. The resignation of several nurses during the project led to a shortage of permanent staff. The implications of this were a greater reliance on agency staff and a perception of decreased time for patient care, especially emotional care. Survey 9 showed another decrease in patients’ evaluation of emotional care. The comments provided by patients during this survey
3. Results 3.1. Quantitative evaluation One hundred and forty-six patients from the study ward were surveyed during the project. In addition, a further 132 patients across the hospital completed the questionnaire to further appraise its psychometric qualities. A total of eleven surveys of patients in the study ward were undertaken. A baseline survey took place before the changes were introduced and the ward was then surveyed every 2 weeks for 5 months. The first survey
Fig. 3. Percentage of level of personal value experienced by patients (questions 1–19).
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Fig. 4. Percentage of best response (all) for each subscale on range of surveys (questions 1–19).
confirmed that patients were aware that time for emotional care was sometimes limited. For example: ‘‘Sometimes the response to a call is slow. There may be a shortage of staff’’ (Patient, Survey 9). ‘‘Great group of people. Appears difficult to cover all aspects of care with amount of people and care required’’ (Patient, Survey 9). ‘‘The only comment I can make is the staff are the greatest. There should be more night staff. There are only a few and a lot of patients. I feel sorry for the night staff’’ (Patient, Survey 9). Although there was a fall in levels of emotional care at certain times during the project, when the final two surveys were performed, high levels of emotional care in all three subscales were again observed (see Fig. 4). While the research project was in progress the annual hospital satisfaction measurement was performed using the Press Ganey Inpatient Satisfaction Survey [26], which had been used in the hospital since 2003. It was noted that the overall rating for the study ward was significantly higher in 2005 than in 2004. An increase in the mean score was reported from 80.7 in 2003 to 86.7 in 2005 ( p < 0.05). This score was also significantly higher than the mean score for the entire hospital. The study ward also scored significantly higher means for 20 individual items out of a total of 38 items. Not all of these items relate to interpersonal interactions, but of special note is the subscale relating to nursing care where 7 out of 8 items were significantly higher than the mean scores for the rest of the hospital. The only item in this section that was not statistically significant related to the promptness of responses to call, but even this improved 4.1 points since the previous survey in 2004 demonstrating an improved trend.
3.2. Qualitative evaluation In-depth interviews with 10 staff were carried out. Eight of these participants were female and two were male. Ages ranged from 21 to 58 years. Five months was the shortest length of time working on the ward and seven years was the longest. Six staff who attended feedback sessions also provided qualitative data which was obtained through detailed notes of their comments regarding their experiences participating in the study. Qualitative data from patients was collected through two indepth interviews with patients, as well as from comments recorded on the PEECH instrument. The qualitative evaluation revealed a number of barriers perceived by staff to prevent the provision of emotional care to patients. Even though there was an overall desire by the staff members who were interviewed to provide emotional care to patients and their families, they often did not always feel able to do this. The reasons for this were identified as: inadequate staffing; ward organisation, routine and culture; lack of privacy; and emotionally distressed staff. Qualitative data provided a greater insight into the results from the PEECH questionnaire. When staff felt that they had been unable to provide emotional care to patients they felt frustrated, concerned, and guilty: . . . you just feel at the end of the day, you feel like you haven’t given them everything that you could because you didn’t have the time and that makes you quite angry. It’s quite frustrating thinking they wouldn’t be so upset if I only had the time to sit down and listen to them. But you don’t because while you’re in there delivering that care, you’ve got bells on, people calling your name, wanting this, needing that (Staff member). The staff who were interviewed said that the introduction of the CCN role eased some of the emotional distress that they
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experienced. This was because, in situations where they felt they were unable to provide the emotional care that they perceived was needed, someone else was available to address this: I think it’s wonderful to have somebody who can provide the missing link . . . it’s a great consolation to know there’s somebody that you can fall back onto, bring into a situation where you’re feeling you’re not doing enough for your patient in that area of coping emotionally with what they’re going through (Staff member). The staff members who were interviewed discussed their experiences with death and reported the need for time after a patient had died, to care for families and themselves. They often developed attachments to specific patients and experienced a deep sense of loss when these patients died, ‘‘. . . people kind of forget that we’re also upset’’ (Staff member). 4. Discussion and conclusion 4.1. Discussion The coordinated approach to emotional care delivery used in this project appeared to be an effective way to increase the emotional comfort and satisfaction experienced by patients on an oncology ward. The use of an Action Research design facilitated the introduction of changes in emotional care, whilst providing insight into the factors that facilitate and hinder emotional care delivery in the clinical setting. Action Research is particularly suited for this type of project because it reveals the reality of a particular situation by the inclusion of the participants in the research process. The manner of this inclusion and contribution is credited with the facilitation of change that is more readily accepted as relevant [27]. The CCN role introduced in this project was found to provide the momentum and leadership necessary for the changes to be incorporated into the everyday practice of all working on the project ward. DeBourgh [28] described the use of an advanced practice nurse for being ideally suited as a ‘‘Champion’’ for change. In a literature review to clarify the concepts in knowledge transfer, Thompson et al. [29] found the role of a facilitator for change to be an useful tool that was described as ‘‘dynamic and active’’ (p. 694). The literature reviewed by these authors found that successful facilitators of change possessed effective interpersonal and communication skills and were able to create a learning environment for change that supported the needs of all those involved with change process. The introduction of a new role of CCN in this study also provided an additional source of emotional care for those patients considered most distressed. Roberts et al. [30] described a similar role of generalist CCN in Melbourne and observed that the use of such roles was not common within Australia. In that study, the role of two nurses was evaluated using a structured telephone interview with 98 patients. Overall, patients were very satisfied with the service, ‘‘Patients reported that they felt more supported and positive, better able
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to cope, less worried and more in control’’ (p. 53). Strong et al. [31] described a pilot study where oncology nurses were trained to screen cancer patients for depression. Although this strategy was assessed as having merit, caution was suggested in such roles with regard to the excessive emotional demands placed on the nurse. A comparable role of CCN is that of specialist breast care nurse and this role has been widely reported in the literature. The use of specialist breast cancer nurses would appear to be a more common occurrence in hospitals than generalist CCNs. Within Australia, Liebert and Furber [32] evaluated the care received by 240 women in New South Wales and found high levels of satisfaction with this role which provided important information and emotional support to women at key points in their treatment. In another study of 63 women who had breast cancer in New South Wales, a survey revealed further support for the role of specialist breast care nurse [33]. However, evaluation of the role of generalist CCN was limited in this current study and further quantitative measurement of the outcomes associated with such a role is warranted. The research-based framework of emotional care introduced in the education and evaluation of this project was readily understood and embraced by the staff who participated in this project. The educational workshops enabled staff to be more purposeful in their emotional care delivery. The use of direct quotes from patients used in the emotional care workshops were said to be extremely powerful and helped staff to gain insight into the world of hospitalised patients. A variety of educational courses have been used in different parts of the world to equip healthcare professional with effective communication skills to provide emotional care for patients. The content of these courses vary and some include novel approaches such as using simulated patients, role-play [34], nominal group techniques [35], and clinical supervision [36] to promote learning. A systematic review of communication skills training for health care professionals working in the field of cancer [37] noted the positive effects of this type of training. However, the outcomes have tended to be measured from the skills level of the participant, rather than from the experience of the participant of care, the patient, as was the case in this current study. Another Australian study which evaluated health professional communication from the perspective of patients was carried out by Trumble et al. [38]. In this study a 3-h communication skills training workshop for doctors was evaluated. Thirty patients of 174 doctors were then asked to evaluate their experience of their doctors’ communication 1 week before the workshop and 3 months afterwards. Statistically significant improvements ( p 0.01) were noted in each of the 10 aspects of communication evaluated. Communication programs for health care professionals have more often been discussed in the literature as part of an undergraduate or postgraduate degree [39,40], than within the hospital setting, as in this current study. Another study which aimed to improve the communication skills of hospital staff took place in China [41] and used a quasi-experimental design to evaluate an integrated communication skills training
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program for 129 nurses in a cancer hospital. The program consisted of a 3-day course followed up by peer support groups at a ward level, managerial support and the provision of a handbook containing further training resources. Statistically significant improvements for all outcomes were recorded for the nurses in the experimental group compared to the control group at 1 and 6 months after training. An integral part of the coordinated approach to emotional care used in this project was the inclusion of ancillary hospital staff and volunteers in the educational program. A review of the literature did not identify any other initiatives within hospitals that had acknowledged the important role that these workers have in terms of emotional care, or provided education to enhance and promote these skills. During this project it was noted that the quality of emotional care delivered to patients was diminished when staff themselves were feeling emotionally distressed. Part of this distress appeared to be related to staff perceiving that it was not always possible to take the time that was needed to provide the emotional care that they felt was needed by patients with cancer. It was hypothesised that the quality of emotional care delivered was diminished when staff themselves were feeling emotionally distressed. This finding would need to be explored further in subsequent work. Similar findings were found in a previous grounded theory study by Williams [5]. In that study nurses working in other setting apart from cancer care, were found to prioritise physical care over emotional care because of a lack of time. A recent survey of nurses working in the United Kingdom (UK) found that the majority (64.6%) believed that they did not have enough time to do their work. This survey also found that 51.9% reported that they could only provide emotional care to patients some of the time [8]. Emotional exhaustion and an intention to leave their current job have been found to be more likely to occur in nurses who worked in environments where a high patient ratio was common [11]. A number of different factors in the work environment of oncology nurses have been reported as being stressful in another study of oncology nurses in Brazil. Factors such as the suffering of patients, not having enough time or physical resources, concern about making errors, and perceiving a lack of support from management, achieved the highest scores in terms of associated stress [42]. Despite the perception by staff that there were times when insufficient time was available for them to provide emotional care to patients, the patients participating in the survey conducted in this study generally reported that the staff on the project ward provided high levels of emotional care. Williams [5] found nurses used a process of ‘‘selective focussing’’ whereby selective patients were given high quality physical and emotional care. High quality care provision was only possible by compromising the care of some patients. A process of ‘‘balancing and compromising’’ was identified by Irurita and Williams [43] as being used by both patients and nurses to preserve each others’ integrity within an environment of limited resources. The use of such processes would explain why high levels of emotional care provision were reported by some
patients, despite the adverse circumstances identified by staff members. 4.2. Conclusion The translation of theory into practice is not an easy task. This paper has described the successful translation of a research-based theory of emotional care into the clinical practice of a ward at St John of God Hospital Subiaco, which cared for patients with cancer. The use of the Action Research method and a clinical champion for emotional care were key elements which led to the success of this project. The new role of a generalist CCN introduced in this project was viewed positively by both patients and staff and appraised as a valuable resource. The hospital-based educational program developed in this project was found to be a useful method of increasing staff’s awareness of the emotional care needs of different patients by providing simple, practical strategies that both professional and non-professional staff could use to contribute to the emotional care of patients. The collaborative partnership between the clinicians and the researchers in this project enhanced the development of this education. The ongoing evaluation of the coordinated approach to emotional care introduced in this project using the PEECH instrument to measure the outcomes from the perspective of the patients, as well as the qualitative data, provided a valuable insight into the factors that facilitate and hinder emotional care provision. A relationship between the quality of emotional care delivery and the emotional wellbeing of staff was hypothesised in this project. This finding supports previous work that has identified factors such as a lack of time, related to staffing issues, as impacting on the delivery of emotional care. It is likely that extended periods of work in such conditions could have a detrimental impact on the wellbeing of the staff, and their ability to deliver quality emotional care. In addition to this, taking into account the nature of the work on the project ward, as well as the large numbers of patient deaths that regularly occurred there, programs of stress management, and avenues for debriefing for hospital staff are likely to be beneficial. Such strategies would help to preserve the emotional integrity of the staff, and may improve their abilities to provide quality emotional care and retention rates. Initiative to address this have already commenced at the study hospital. It is critical that impact of environmental factors on the wellbeing of staff is considered and addressed as part of any program that is directed at improving the emotional care delivered to patients. 4.3. Practice implications Consider use of the Action Research method in combination with a clinical champion when introducing change into the clinical setting. The generalist Cancer Care Nurse role offers an additional source of support for emotionally distressed patients. Further investigation into the outcomes associated with the role of the generalist Cancer Care Nurse.
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Emotional care for hospitalised patients may be improved by using a coordinated educational approach for staff, including ancillary staff and volunteers. Further investigation into the relationship between the emotional wellbeing of hospital staff and emotional care delivery is warranted.
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Acknowledgements
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This research was funded by the National Health and Medical Research Council Grant ID 274906 and an Industry Collaboration Grant from Edith Cowan University and St John of God Hospital Subiaco. We gratefully acknowledge the following for their support and contribution to this project: patients and staff participants; supporting staff at St John of God Hospital Subiaco: Danielle Darragh, Vivienne Garrick, Chris Hanna, Joan Jessup, Michaela Kilroy, Dr. Siobhan Ng, Dr. David Ransom, Sue Terry, and the Psychosocial Care Committee at St John of God Hospital Subiaco: Michael Brennan, Vicki Brown, Valerie Colgan, Anne Fox, Jennifer Gardner, Rita Paglia, Deborah Pearson, and Julie Teraci. As well, the assistance of Rebecca Osseiran-Moisson, Aurora Popescu, Therese Shaw and Sandra Pereira in the statistical analysis aspects of this project was appreciated.
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