Service development

Establishing a nurse practitioner

collaborative: evolution, development,
and outcomes
Karen Quinn, Peter Hudson

he advanced clinical practice role of the

nurse practitioner (NP) has been well
established in North America for several
decades and across a range of specialties (RyanWoolley et al, 2007; Poghosyan et al, 2012). The
NP role in Australia and the UK is a relatively
new initiative that commenced in the early 2000s
(Gardner et al, 2009). There are over 1000 NPs
across all states and territories of Australia, of
whom approximately 130 work in the state of
V ictoria (V ictorian G overnm ent H ealth
Information, 2012). Australian NPs work across
a range of specialties, including palliative, emer
gency, older person, renal, cardiac, respiratory,
and mental health care.
There has been increasing focus nationally and
internationally on developing academic pro
grammes specifically for nurses working toward
NP status (Gardner et al, 2006). There has been
less emphasis on identifying the comprehensive
clinical support requirements for NPs and NP
candidates (NPCs) to ensure they meet all regis
tration requirements to achieve and/or maintain
endorsement, or on articulating the ongoing
requirements for NPs once endorsed.
Historically in Australia there has been a lack of
clarity and limited published evidence on the
benefits of the NP role for patients, carers, and
health services (Quaglietti et al, 2004; Gardner
and Gardner, 2005; Bookbinder et al, 2011; Dyar
et al, 2012). An NP is considered to be at the apex
of clinical nursing practice. The NP role typically
entails comprehensively assessing and managing
patients, prescribing medicines, making direct
referrals to other specialists and services, and
ordering diagnostic investigations (Australian
Nursing and Midwifery Council, 2009).
All NPs in Australia are required to meet the
following generic criteria: be a registered nurse,
have completed a Nursing and Midwifery Board
of Australia approved postgraduate university
Masters (nurse practitioner) degree programme,
and be able to demonstrate a minimum of 3
years experience in an advanced practice role

2 0 14 M A Healthcare Ltd

International Journal o f Palliative N ursing 2014, V o l 20, N o 9

A bstract
The firs t A ustralian palliative care nurse p ra c titio n e r (NP) was
endorsed in 2003. In 2009 the Victoria Departm ent o f Health funded
the development o f the Victorian Palliative Care Nurse Practitioner
Collaborative (VPCNPC). Its aim was to prom ote the NP role, develop
resources, and provide education and m entorship to NPs, nurse
practitioner candidates (NPCs), and health service managers. Four key
objectives w ere developed: id e n tify the dem ographic p ro file o f
palliative care NPCs in Victoria; develop an education curriculum and
practical resources to support the training and education o f palliative
care NPCs and NPs; provide mentorship to NPs, NPCs, and service
m anagers; and ensure e ffe c tiv e c o m m u n ic a tio n w ith all key
stakeholders. An NPC survey was also conducted to explore NPC
demographics, models o f care, the hours o f study required fo r the role,
the mentoring process, and education needs.This paper reports on the
e stab lish m en t o f the VP C N P C , th e steps taken to achieve its
objectives, and the results o f the survey.The NP role in palliative care
in Australia continues to evolve, and the VPCNPC provides a structure
and resources to clearly articulate the benefits o f the role to nursing
and clinical services.
Key words: Nurse p ra ctitio n e r
Advanced nursing Education

C ollaborative

(Nursing and Midwifery Board of Australia,

2011). An NPC in Victoria is a registered nurse
employed by a service or organisation to work
toward meeting the academic and clinical require
ments for national endorsement as an NP. During
the period of candidacy, which is of variable dura
tion, NPCs consolidate their competence to work
at the advanced practice level of an NP. The can
didacy period is a process of learning the new role
while engaging with mentors (medical and nurs
ing) and accessing other learning opportunities
both within and outside ones organisation to
meet the educational requirements. Integral to the
NP role is the development of a model of care
that is responsive to identified service delivery
gaps that can be addressed by the skills, knowl
edge, and expertise of an NP. These are unique to
each individual service. The practice of an

Palliative care

Karen Quinn,

Coordinator
Education, Centre for
Palliative Care; Project
Officer, Victorian
Palliative Care Nurse
Practitioner
Collaborative, PO Box
2900, St Vincents
Hospital Melbourne,
Australia; Peter
Hudson, Director,
Centre for Palliative
Care, St Vincents
Hospital Melbourne;
Professor of Palliative
Care, Queens University,
Belfast, Northern
Ireland

Correspondence to:
Karen Quinn
karen.quinn@
svhm.org.au

4S7

Service development

Objective

Action

O u tco m e
7 o f 13 NPCs responded
M ajority aged 4 0 -5 0 years
Mean o f 1 1 years o f palliative care
experience
*>

Identify the

O ver half o f NPCs are full-tim e NPCs

NPCs enrolled in Masters courses

demographic profile

allocate 2 0 -27 hours/week o f own

and learning and

tim e to study

mentorship needs o f

Survey distributed

palliative ca*e NPCs

to NPCs in

in V ictoria

V ictoria

M ajority review patients in aged care

facilities
Clearly identified learning needs

Develop an

Professional netw orking opportunities

education curriculum

Avenue fo r sharing experiences and

and practical
resources to support
the training and
education c f

concerns
Lead quarterly
forum s
Identify ongoing

palliative ca-e NPCs

learning

and NPs

resource needs

Provide m entorship

a Case study presentation opportunities

Palliative Care NP Clinical
Competencies
e Palliative Care NP Symptom
Assessment Guide
Position descriptions developed

to NPs, NPCs, and

A ppo in t mentors

service maragers

fo r each group

Regular evaluation o f num ber and

nature o f enquiries
Website acts as repository fo r resources

Ensure effective

Develop website

Regular e-new letters to all members

C onsider o th e r

Special interest group fo r NPs and NPCs

com munication w ith

com munication

O nline discussion forum

all key stakeholders

strategies

Map o f NPs and NPCs

NPC, nurse practitioner candidate; NP, nurse practitioner;VPCNPC,Victorian Palliative

Care Nurse Practitioner Collaborative

Australian NP is guided by national standard;

{Nursing and Midwifery Board of Australia
2014). It is defined by four overarching standards:
clinical, education, research, and leadership.
Following the initial endorsement of four
Victorian palliative care NPs in 2005, there was a
lull in recruitment. The Victoria Department of
Health (DH) recognised the potential benefits of
NPs for health services, and in 2008 it provided
funding for Victorian public health services to
scope palliative care NP models of care that could
enhance service delivery and patient outcomes.
The scoping strategy was effective and led to the
appointment of 16 palliative care nurses to NPC
positions over the ensuing 3 years. The NPC;
work across a broad range of care settings, includ
ing inpatient, community, and outpatient in metro
politan, regional, and rural areas of Victoria.
At the same time, the DH also funded the
Centre for Palliative Care to establish the
Victorian Palliative Care Nurse Practitioner
Collaborative (VPCNPC) to support the NPs and
NPCs. The Centre is a state-wide service that i;
part of St Vincents Hospital Melbourne and a
458

collaborative Centre of the University of

Melbourne. Its primary function is to provide
training and conduct research in palliative care.
The purpose of the VPCNPC was to provide sup
port and mentorship and develop resources tar
geted at palliative care NPs, NPCs, and health
service managers. Membership of the VPCNPC is
open to all NPs, NPCs, health service managers,
and nurses interested in the NP role.
The aim of this paper is to describe the devel
opment of the VPCNPC, its actions, and the out
comes of these actions.

Development of the VPCNPC

The initial step for the VPCNPC was to establish
a governance structure, which included appoint
ing a management committee to oversee and pro
vide advice on all activities. Key stakeholders
were invited onto the management committee,
which went on to comprise a representative from
the DH, an experienced palliative care NP
engaged as a clinical advisor, a clinical health
service manager, a community palliative care
service representative, a palliative care physician,
an academic, and a project officer.
The management committee developed four
objectives to inform the strategic direction of the
VPCNPC and guide its activities:
Identify the demographic profile, including the
learning and mentorship needs, of palliative
care NPCs in Victoria
Develop an education curriculum and practical
resources to support the training and education
of palliative care NPCs and NPs
Provide mentorship to NPs, NPCs, and service
managers
Ensure effective communication with all key
stakeholders.

Actions and outcomes

Table 1 provides a summary of actions and out
comes related to each of the four objectives.

Demographic profile and learning and

mentor needs o f palliative care NPCs
in Victoria
A survey was developed by the VPCNPC man
agement group to determine the demographic
profile of palliative care NPCs, the range and
diversity of NPC models of care across Victoria,
the hours of study required for the role, mentor
ing arrangements, and NPC education needs. The
survey received ethical approval from St Vincents
Hospital Melbourne and was mailed to the 13
current NPCs. Seven NPCs completed the survey.
Three of the seven NPCs were male and five
were 40-50 years of age. They had been regis-

International Journal o f Palliative N ursing 2014, Vol 20, No 9

2014 MA Healthcare Ltd

T a b le 1. A c t io n s a n d o u t c o m e s r e l a t e d t o V P C N P C o b je c t iv e s

Service development

2014 MA Healthcare Ltd

tered nurses for 13-33 years (mean 22 years) and

had been w orking in palliative care for 4 -19
years (mean 11 years). Four candidates held post
graduate qualifications other than NP M asters
degrees. Four candidates had completed their NP
M asters degrees and three were working toward
them. Four candidates worked full-time in their
NPC role and three part-time. These three com
bined their part-time NPC role with either a clin
ical nurse consultant role or quality assurance
project activities. Four NPCs worked in inpatient
settings and three in community settings.
NPCs who were completing their NP M asters
degrees were devoting 20-27 hours per week of
their own time to study. NPCs who had com
pleted their NP M asters committed 3-5 hours
per week. In terms of professional development
in paid working hours, three candidates were not
allocated any hours for work-related study; the
remainder were allocated 1-10 hours per week.
Four NPCs were able to provide a clear
descrip tio n of th eir m odel of care, w hich
included responsibility for complex symptom
management across a range of settings. Three
said their model was in development. The four
models described all involved enhancing patient
or client access to services and symptom review
in residential aged care settings.
All seven NPCs had identified medical mentors.
Five stated that there was no formal process to the
medical mentor meetings, while two reported that
the meetings were structured around case study
discussions or informed by clinical experience since
the previous meeting. Two NPCs reported having
an identified nursing mentor, but neither had a
structured approach to the meeting schedule or
format. Five candidates were not able to identify a
mentor who could provide clinical leadership and
professional support to the new NPC role.
E ducation needs identified by the NPCs
included developm ent of skills in conference
presentations and preparing conference abstracts
(=3); conducting mental health assessments and
learning about cardiac, respiratory, and neurolog
ical illnesses, pathology, and diagnostics (n=6);
development of clinical assessment skills (n=3);
leadership (=2); and opportunities for place
ment in specialist areas including mental health,
chronic disease, and a palliative care setting dif
ferent to their own (=4).

Curriculum and practical resources to

support the training and education of
palliative care NPCs and NPs
Quarterly 6-hour forums were established as a
face-to-face opportunity for NPs and NPCs to
network with each other, share experiences and

International Journal o f Palliative N ursing 2014, Vol 20, N o 9

Box I.VPCNPC education curriculum top cs

End-stage ion-m alignant diseases,

e Advance care planning

including cardiac, renal, and respiratory

Requirements to r prescribing
Conducting a mental health assessment
Preparing and presenting case studies
Conducting a physical assessment
Understand rg the role o f a m entor
Leadership in palliative care
Interpreting abdom nal and chest X-rays
Management skills in palliati/e care
Ethical challenges in palliative care
Literature searching skills
Preparing f c r pub ic itio r and
Research considerations
Teaching a- d learning sty as
Palliative c are and adolescent issues

dissemination
Supportive decision making from
th e o ry to practice

challenges, participate in education, and present

and discuss clinical case studies. At each forum
the attendees are invited to identify their learning
needs. The responses so far have been collated
and an education strategic plan has been devel
oped. The plan focuses on ensuring education is
clinically relevant and complements the academic
courses undertaken by NPCs (focusing primarily
on the specialty of palliative care practice) as well
as on compiehensively evaluating all education
and related activities.
Invitations to attend the forums are circulated
widely to padiative care N?s, NPCs, nurses inter
ested in the NP role, and health service managers.
As a means of meeting the education needs iden
tified in objective 1, education sessions are con
sidered a critical com ponent of each forum.
Participants are encouraged to prov.de feedback
on each of "he forums. Responses so far were
collated and formed the oasis of a curriculum
tBox 1). Eaca forum features a case presentation
and discuss.on led by one of the NPCs. The
forums provide a unique opportunity for peer
support among the NPs. NPCs, and service man
agers and enable them t:> practice their presenta
tio n sk ills and learn from each o th e rs
experiences. As the NP role incorporates leader
ship and teaching as well as advanced practice,
the education sessions include w orkshops on
leadership, management, teaching strategies, liter
ature search.ng, and publication advice.
The NPCs consistently reported via forum
evaluation reedback that they were seeking a
framework t.aat would provide indicators of how
to achieve the NP clinical competency standards.
The VPCNFC therefore established a core writ
ing group, consisting of academics, an NP, and a
palliative cere nurse to develop Padiative Care
NP Clinical Competencies During the consulta
tion process it was agreed that the final docu
ment would reference and link with each of the
National NP Competency Standards and include
key performance indicators and assessment prin-

4S9

Service development

Mentorship for NPs, NPCs, and service

managers
Mentorship is key to supporting NPCs, NPs, and
clinical service managers as they embed the NP
role into a service. Informed by consultation with
experienced palliative care clinicians in the
VPCNPC, three specific mentor roles were devel
oped for medical, nursing, and palliative care
service manager advisors.
The medical advisor was an experienced spe
cialist palliative care physician whose primary
focus was on providing advice for rural palliative
care NP services, which may not have regular
access to a palliative care doctor. In addition, the
role incorporates working with metropolitan
services to support the NP.
The nurse advisor was an endorsed palliative
care NP who provided professional support and
advice to rural and metropolitan NP services and
NPCs via phone or email. The nurse advisor
assisted NPs and NPCs to identify and imple
ment their professional development plans and
promoted networking with providers of palliative
care services. They also assisted in developing
and implementing guidelines and policies specific
to the NP role.
The clinical service advisor was a manager of a
community palliative care service that employed
an NP and was therefore familiar with the NP
role and the process of embedding it in a service.
The service manager responded to queries (usu
ally by phone or email) from service managers
considering an NP or NPC role.
A review of the number of interactions, the
approximate time taken, and the nature of enquir
ies for the medical, nursing, and service manager
mentors was routinely conducted at each of the
quarterly management meetings. This monitored
the demand for mentorship and ensured it was
460

sustainable over time and not burdensome to the

mentors. Mentor enquiries primarily related to
seeking clarification about the NP role and how
best to source face-to-face clinical mentoring when
it was not readily available in their service. The
mentors provided advice and recommendations
for ensuring NP and NPC needs were met.

Effective communication with all key

stakeholders
Effective communication was vital to ensuring
consistency and regular access to all relevant
information regarding VPCNPC activities. The
communication strategy included the following:
Development of a VPCNPC website (http://
centreforpallcare.org/index.php/education/vpcnpc) that is regularly updated with information
and resources relevant to health services, NPs,
NPCs, and nurses interested in finding out
more about the NP role
0 Development of an e-newsletter with updates
on upcoming activities
Formation of a special interest discussion
group for NPs and NPCs
0 Establishment of an online forum for NPs and
NPCs to share experiences and peer support
0 Collation of NP and NPC details including a
description of each model of care, contact
details, and proposed date for NPCs to achieve
endorsement that are shared with all NPCs
(with permission)
0 Presentation of VPCNPC updates regularly at
relevant conferences
0 Development of a map of palliative care NP
and NPC locations in Victoria (accessed via the
VPCNPC website).

Discussion
The total number of Victorian NPs and NPCs
has steadily increased since the inception of the
VPCNPC in 2009, when there were four NPs and
two NPCs. Although there are still few palliative
care NPs (currently 11) and NPCs (also 11) in
Victoria, there is increasing interest in the role
from nurses and clinical health services.
All NPCs have been offered NP roles with the
same organisation in which they were a candi
date, once they have met all the requirements and
been endorsed as an NP. This suggests that the
clinical services were satisfied with the value that
the advanced practice NP role could add to
patient and carer outcomes.
The next steps for the VPCNPC include for
mally evaluating the experiences of clinical serv
ices that employ NPs and NPCs in terms of
benefits and cost-effectiveness. Given that several
nurses have now been working as NPs in excess

International Journal o f Palliative N ursing 2014, Vol 20, N o 9

2014 MA Healthcare Ltd

ciples that would provide evidence of compe

tence. All members of the VPCNPC were invited
to review the first draft, which was then refined.
National and international NPs, palliative care
physicians, policy developers, academics, and a
pharmacist were invited to review the second
draft. Based on the feedback, the draft was fur
ther refined to the final version of the Palliative
Care NP Clinical Competencies. The document is
available via the Centre for Palliative Care web
site (www.centreforpallcare.org.au).
With the aim of providing NPs and NPCs with a
guide to conducting patient symptom assessment, a
second document was developed based on a simi
lar approach to the competencies. The Palliative
Care NP Symptom Assessment Guide is also avail
able via the Centre for Palliative Care website.

2 0 14 M A H e a lth c a r e L td

Service development

of 2 years, it would be useful to explore their

experiences and recommendations for the benefit
of all nurses interested in the role.
The activities of the VPCNPC have been
guided and informed by the four objectives devel
oped by the management group and by the needs
identified by the VPCNPC members. For exam
ple, the evaluations undertaken at each of the
quarterly forums have informed a curriculum to
meet the learning needs of palliative care NPs
and NPCs. The curriculum was further enhanced
by the results of the NPC survey. All VPCNPC
education is evaluated by the participants, and
the education programmes were reviewed based
on the feedback responses.
All members of the collaborative value the
opportunity for collegial interaction via a range
of strategies, including face-to-face meetings, the
website, peer contact, focused education sessions,
and resources developed specifically to meet their
needs. One useful aspect of the regular forums is
the opportunity to discuss experiences with other
NPs and NPCs. Time in each forum is allocated
to collegial discussion (led by an experienced NP)
and sharing of strategies to problem-solve issues
of concern that would not necessarily be identi
fied in a formal education session.
The resources developed by the VPCNPC,
including the P alliative Care NP C linical
Competencies and Assessment Guide, have been
informally evaluated as being useful to NPs and
NPCs and are freely available to all nurses inter
ested in exploring the NP role. A future project
will formally evaluate and revise these resources.
The information and resource needs of the clini
cal service managers continue to emerge as the
managers become more familiar with the NP role.
A resource kit for clinical services could be a valua
ble tool. This could include examples of effective
models of care developed by other services, ques
tions for services to consider to inform the need for
an NP, clear articulation of the role and the respon
sibilities of the service in supporting NPs and
NPCs, contact details for service managers willing
to engage with and mentor services new to the role,
and strategies to implement access to services (e.g.
radiology and pathology) not otherwise available.
Despite being strongly recommended, regular
structured nursing and medical mentorship were
not always accessible to the NPs and NPCs sur
veyed. M entoring also varied between NPs and
NPCs. Therefore, services are encouraged to
think creatively about ways to respond to NPCs
learning needs. There is a need for increased clar
ity about the role of clinical m entorship, the
process, and m entor responsibilities regarding
NPC clinical competency assessment.

International journal o f Palliative N ursing 2014, Vol 20, N o 9

The NPC survey was limited by the small sam

ple size, and therefore the results and recommen
dations are not necessarily transferable to a wider
cohort. Repeating the survey with a larger sample,
perhaps involving all NPCs and NPs regardless of
their specialty area of practice, may help to deter
mine whether needs vary across the groups.

Conclusion
The VPCNPC has continued to evolve and grow
as NPs, NPCs, and clinical service managers
become more familiar with the requirements and
responsibilities of supporting nurses to achieve NP
competency. It has developed a model and struc
tured education curriculum and resources that
respond to the unique needs of palliative care NPs,
NPCs, and clinical service managers. Further
research is required to evaluate the benefits of the
NP to the key stakeholderspatients, carers,
health professionals, and clinical services, ijpn
Declaration o f interests
The VPCNPC is funded by the Departm ent o f Health
Victoria. The authors have no conflicts o f interest to
declare.

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tered Nurses. Standards and Criteria for the Accredita
tion o f Nursing and Midwifery Courses Leading to Reg
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(accessed 11 August 2014)
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practitioner-based models of specialist palliative care at
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461

Research roundup

Synopses o f a se le ctio n o f re c e n tly p u b lis h e d research a rticle s o f relevance to p a llia tiv e care.

In recognition of the im portance of

evaluating palliative care services in a
standardised and valid format, Leemans
et al produced a comprehensive set
of quality indicators against which to
measure palliative care services across
Belgium. This m ixed-m ethods study
combines quantitative analysis and
qu alitativ e interview s to evaluate
the quality indicators for their face
validity, feasibility, discriminative power
and usefulness.
There were 85 quality indicators
across nine quality domains relating to
standards in physical, psychological and
social treatment and care, coordination
and continuity of care, family and carer
support, inform ation, communication
and decision making, and type and
structure of care at the end of life. These
indicators were implemented across nine
palliative care services across Belgium,
and then measured via questionnaire,
and subsequently interview, by a sample
of p atien ts (n = l 16), professio n al
caregivers (n= 121), fam ily carers
(n = 193), and physicians (n=192).
The response rate was highest for
professional caregivers (97%), followed
by physicians (65% ), then patients
(56%) and family carers (56%).
Five (5.9%) of the indicators were
evaluated as not being useful for quality
improvement and 20 (23.5%) had too
many missing answers, i.e. feasibility
issues. O ther than this, indicators
appeared to be evenly d istributed,
dem onstrating good discrim inative
power. They were also evaluated as
being valid in terms of measuring the
relevant quality. Results indicated that
most respondents found the instrument
im portant and useful, but felt that
the set of quality indicators should be
smaller, while remaining comprehensive.
In response to the resu lts, one
indicator was removed, and the rest
were revised accordingly. The new set
is ready for evaluation and the authors
hope that once it is complete and in
462

systematic use across Belgium, it will

be used to evaluate palliative care
services at home and in hospital against
national and international standards,
continually improving them to achieve
higher quality care for patients and their
families at the end of life. However,
the authors note the need for both
researchers and policy makers to further
investigate and identify the optimal
circumstances for quality comparison.
Leemans K, Deliens L, Francke AL, Stichele RV,
Van den Block L, Cohen J (2014) Quality indi
cators for palliative care services: mixed-meth
od study testing for face validity, feasibility
discriminative power and usefulness. Palliat
Med 2 September [Epub ahead of print] doi:
10.1177/0269216314546712

Conducting transparent and ethical

research in resource-restricted
settings: a Kenyan evaluation
Since the widespread availability of
antiretroviral (ART) therapy in subSaharan Africa, no evidence has been
collected to evaluate a holistic model of
palliative care for HIV-positive patients
receiving this treatment. To determine
the effectiveness of a nurse-led palliative
care approach for this patient group,
Lowther et al conducted a randomised
controlled trial (RCT) in an urban clinic
in Mombasa, Kenya. The results of the
trial will be published at a later date.
This article presents detailed data relating
to the recruitment process, refusal to
participate, randomisation and missing
data in this study in the interest of
transparent reporting, which, the authors
note, is particularly important in crosscultural settings and when conducting
research with vulnerable populations.
Over 5.5 months, 2070 patients were
screened. Inclusion criteria specified
adult HIV-positive patients who had
been on ART for more than 1 month. Of
those deemed to be eligible (1664/2070;
80 .4 % ), 151 (55.7% ) refused to
participate and 120 (44.3%) consented.
The intervention consisted of at least
seven multidimensional, person-centred
sessions with a trained nurse over a
period of 4 months. Data were collected
via interview at baseline, and study

participants (n=120), who were recruited

consecutively from the HIV clinic at the
study site, were then allocated to either
a control (n=60) or intervention group
(n=60), using block randomisation.
Participants in the control group
received standard HIV care according
to current best practice: assessment
by doctors and/or nurses, repeat
prescriptions of ART, referrals to
adherence support for ART and other
nutrition or community support referrals
as appropriate. The intervention group
received the same standard care;
however, they also received additional
sessions with the HIV nurses who were
trained over 8 weeks in the palliative
care approach by the Kenyan Hospice
and Palliative Care Association.
The authors, based in the UK and
Kenya, concluded that it is possible to
ethically conduct an RCT in a resourcelimited setting. Their findings indicate
th a t recruitm ent procedures were
appropriate, missing data were minimal
and low participant attrition indicates
the clarity of the informed consent
process and the authors commitment
to ethical recruitment procedures.
The authors hope that researchers
continue to transparently report their
experiences and that this publication
will be used to inform further RCTs in
this area of study.
Lowther K, Higginson IJ, Simms V et al (2014)
A randomised controlled trial to assess the ef
fectiveness of a nurse-led palliative care inter
vention for HIV positive patients on antiretro
viral
therapy:
recruitment,
refusal,
randomisation and missing data. BMC Re
search Notes 7(600): 1-10

UK researchers examine the scope

and breadth of social media
platforms to discuss end-of-life care
In light of the increasingly open
dialogue, particularly online, around
death and dying, Nwosu et al from the
UK conducted a retrospective analysis
over 2 years to analyse its frequency,
content, tone and acceleration. Between
1 August 2011 and 31 July 2013, social
media analytics tool, TopsyPro, was
used to identify and analyse tweets on

2 0 14 M A Healthcare Ltd

Measuring Belgian palliative care

services on national and
international scales

Research roundup

2014 M A Healthcare Ltd

Twitter containing palliative care terms in

the forms of hashtags or phrases.
Some 13 palliative care terms were
identified from a total of 683.5K tweets
over a 2-year period. The most popular
terms were end of life (210K) and
palliative care (93.8K) and the most
popular hashtag (#) was #hpm (114K)
(hospice and palliative medicine). In
terms of acceleration or trending, the
term Liverpool Care Pathway spiked
by 55%, peaking in July 2013, as might
be expected with the independent review
being published that month.
Tweet volume for all palliative-related
terms increased considerably by 62.3%
between the 2011-12 and 2012-13 time
points. TopsyPro allows for analysis of
how positive or negative the sentiment
of selected tweets are in relation to
the o th er tw eets posted th a t day.
Interestingly, 89% of palliative terms
were classified as more positive than
all of the terms mentioned on Twitter
during the 2-year study period.
The greatest volum e of relevant
tweets appeared to be sent from Englishspeaking countries, with 58.1% from
the USA, 21.8% from the UK and
6.6% from Canada. However, as only
English search terms were included in
the analysis, potentially relevant terms
in other languages were likely missed, as
acknowledged by the authors.
The authors concluded that not only
are discussions about the end of life
on the rise in volume and frequency,
but they are largely positive. This
signals a gradual shift from the taboo
perception of discussions around death,
dying and end-of-life care tow ard a
more open acceptance of this subject.
The a u th o rs suggest th a t social
media tools, such as Twitter, provide
a novel platform for ongoing dialogue
in end-of-life care, both personally and
professionally, and recommend further
qualitative and quantitative analysis of
the impact of this digital discussion on
engaging wider society.

Nwosu AC, Debattista M, Rooney C, Mason S

(2014) Social media and palliative medicine: a
retrospective 2-year analysis of global twitter
data to evaluate the use of technology to
communicate about issues at the end of life. BMJ
Support
Palliat
Care
2
September
[Epub
ahead
of
print]
doi:10.1136/
bmjspcare-2014-000701

The efficacy of the Liverpool Care

Pathway in the Netherlands:
barriers and facilitators
Although the Liverpool Care Pathway
(LCP) was recently replaced in the UK
following concerns about the tick-box
nature of its use, its original aim in the
1990s was to transfer the gold standard
of care provided in UK hospices to
other settings in which dying patients
receive care. Raijmakers et al conducted
a qualitative study to investigate its
efficacy in the Netherlands, where it was
introduced in 2001.
Telephone interviews were conducted
w ith 28 stakeholders involved with
the implementation of the LCP in the
Netherlands. These included consultants
from the C om prehensive C ancer
Centre of the N etherlands (CCCN),
palliative care network coordinators
and project leaders of the organisations
im plem enting the LCP. The LCP
is in place in over 100 health-care
organisations in the Netherlands. The
CCCN consultants, who were asked to
identify organisations that successfully
implemented the pathway, mentioned a
total of 25 organisations, 10 of which
were selected to guarantee a variety of
geographical regions and organisational
settings. Subsequendy, consecutive focus
groups, led by an experienced moderator,
were held with eight interviewees to
discuss and validate the findings from
the interviews. All transcripts from both
interviews and focus groups were then
transcribed and thematically analysed.
In a d d itio n to th e e sse n tia l
com ponent of ensuring m otivated
health professionals and management
to drive the improvement of end-of-life
care, the authors identified facilitators
for successful im plem entation of
an instrum ent such as the LCP as
being: quality and completeness of the
instrument, a multidisciplinary project
team, and liaison with important parties
within and outside the organisation in
which it is being implemented. However,
the authors also recommended that
tasks be disentangled from the project
leader and formally integrated into
organisational quality systems.
Raijmakers N, Dekkers A, Galesloot C, van
Zuylen L, van der Heide A (2014) Barriers and
facilitators to implementation of the Liverpool

Care Pathway in the Netherlands: a qualitative

study. BMJ Support Palliat Care 8 September
[Epub
ahead
of
print]
doi:10.1136/
bmjspcare-2014-000684

Predicting the survival of advanced

cancer patients via levels of
consciousness in Taiwan
To improve the accuracy of prognoses
given to patients at the end of life,
Tsai et al conducted a prospective
observational study to assess the ability
of levels of consciousness to predict the
survival of advanced cancer patients,
as a deterioration of consciousness has
been reported near death.
Patients (n=531) were recruited from
a palliative care unit in Taiwan and
their status on admission and 1 week
later were recorded as either normal
or impaired. Of the 531 patients, 60%
(n=317) were recorded to have normal
levels of consciousness at admission.
These patients were found to have a
longer survival time than the remaining
40% (n=214) who were deemed to have
impaired consciousness at admission
(17.0 days versus 6.0 days, p<0.001).
Of these 317, 146 maintained normal
consciousness after the first week. Of
the 214 who were recorded as having
impaired consciousness, 20 returned to
normal consciousness. When measured
again 1 week after admission, those with
normal consciousness at admission had
a higher survival percentage than those
with impaired consciousness (78.9%
versus 44.3%, p<0.001). Furthermore,
patients who were normal at admission
and normal 1 week later, and those who
were impaired at admission but normal
1 week later, both had better survival
rates than those who were either normal
at admission and impaired 1 week
later or impaired at admission and still
impaired 1 week later. The authors
concluded that measures of consciousness
taken 1 week post admission should be
integrated into the survival prediction of
advanced cancer patients.
Tsai J-S, Chen C-H, Wu C-H et al (2014) Con
sciousness Levels One Week after Admission
to a Palliative Care Unit Improve Survival
Prediction in Advanced Cancer Patients. /
Palliat Med [Epub ahead of print] DOI:
10.1089/jpm.2014.0220

A ysha M endes da M ata

Freelance journalist

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