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1.  The development, implementation and evaluation of an outpatient palliative radiotherapy programme 
Purpose
Improve the quality of integrated care and support to oncology outpatients receiving palliative radiotherapy.
Theory/background
Oncology patients receiving palliative radiotherapy experience major transitions. These patients are currently offered shortened outpatient treatment. In 2004–2005, research by RU students showed deficiencies in information, continuity in care, and in communication between health care providers. To improve integrated care and transmural cooperation multidisciplinary teams contributed to developing a protocol and checklist called ‘Transmural Programme Palliative Radiotherapy’ (TZPR).
Method
The RU Centre of Expertise Transitions in Care evaluated the process of regional implementation and the value of TZPR on patient and organizational level. Themes were needs, logistic process, symptom control, psychosocial support and after-care. A mixed methods design was used: semi-structured interviews with 20 caregivers and patients; a focus group discussion with 7 caregivers; a questionnaire for both patients and control group.
Results/conclusion
Health professionals are positive about the content and implementation of TZPR. They experienced an improvement in the quality of integrated care and support to patients. Preliminary results from the patients' perspective are expected mid-2009. The participatory approach guarantees the desired integrated care.
PMCID: PMC2807066
palliative care; radiotherapy; oncology patients; quality of care
2.  Understanding Transitions in Care from Hospital to Homeless Shelter: a Mixed-Methods, Community-Based Participatory Approach 
Journal of General Internal Medicine  2012;27(11):1484-1491.
ABSTRACT
BACKGROUND
Coordinated transitions from hospital to shelter for homeless patients may improve outcomes, yet patient-centered data to guide interventions are lacking.
OBJECTIVES
To understand patients’ experiences of transitions from hospital to a homeless shelter, and determine aspects of these experiences associated with perceived quality of these transitions.
DESIGNS
Mixed methods with a community-based participatory research approach, in partnership with personnel and clients from a homeless shelter.
PARTICIPANTS
Ninety-eight homeless individuals at a shelter who reported at least one acute care visit to an area hospital in the last year.
APPROACH
Using semi-structured interviews, we collected quantitative and qualitative data about transitions in care from the hospital to the shelter. We analyzed qualitative data using the constant comparative method to determine patients’ perspectives on the discharge experience, and we analyzed quantitative data using frequency analysis to determine factors associated with poor outcomes from patients’ perspective.
KEY RESULTS
Using qualitative analysis, we found homeless participants with a recent acute care visit perceived an overall lack of coordination between the hospital and shelter at the time of discharge. They also described how expectations of suboptimal coordination exacerbate delays in seeking care, and made three recommendations for improvement: 1) Hospital providers should consider housing a health concern; 2) Hospital and shelter providers should communicate during discharge planning; 3) Discharge planning should include safe transportation. In quantitative analysis of recent hospital experiences, 44 % of participants reported that housing status was assessed and 42 % reported that transportation was discussed. Twenty-seven percent reported discharge occurred after dark; 11 % reported staying on the streets with no shelter on the first night after discharge.
CONCLUSIONS
Homeless patients in our community perceived suboptimal coordination in transitions of care from the hospital to the shelter. These patients recommended improved assessment of housing status, communication between hospital and shelter providers, and arrangement of safe transportation to improve discharge safety and avoid discharge to the streets without shelter.
doi:10.1007/s11606-012-2117-2
PMCID: PMC3475815  PMID: 22707359
discharge care; homelessness; quality of care; community-based participatory research; mixed methods
3.  Lived experiences of pediatric oncology nurses in Iran 
Background:
Caring is a valuable task. The staff in any profession that involves patients’ fear, anxiety, pain, and suffering may experience similar feelings. As a professional group, oncology nurses deal with patients and their relatives and caregivers under very stressful conditions. They encounter pain, suffering, and death as a part of their daily life. A number of studies have evaluated the experiences of pediatric oncology nurses in other countries. Therefore, conducting a survey about the experiences of Iranian nurses of caring for children with cancer can reveal their demands, stress, and limitations.
Materials and Methods:
In a qualitative research, in-depth, unstructured individual interviews with open-ended questions were conducted to evaluate the experiences of pediatric oncology nurses in a hospital in a metropolitan city of Iran. The subjects all consented to participate and had at least one year of working experience in the ward. Content analysis was performed to analyze the data.
Results:
The lived experiences of pediatric oncology nurses were categorized in five main themes. These themes included attachment, supportive care, trying to repress feelings, feeling of helplessness, and the need to be supported.
Conclusions:
According to these results, nurses who provide care for children with cancer require support. This research also highlighted the roles, limitations, and needs of nurses in pediatric oncology wards.
PMCID: PMC3877455  PMID: 24403935
Iran; lived experiences; pediatric oncology nursing qualitative research
4.  Changes in Caregiver Perceptions Over Time in Response to Providing Care for a Loved One With a Primary Malignant Brain Tumor 
Oncology nursing forum  2011;38(2):10.1188/11.ONF.149-155.
Purpose/Objectives
To examine how family members of patients with a primary malignant brain tumor transition into the caregiver role and how their perceptions of this transition change over time.
Research Approach
Descriptive, qualitative.
Setting
Neurosurgery and neuro-oncology clinics of a regional medical center.
Participants
10 family caregivers of patients with a primary malignant brain tumor.
Methodologic Approach
A series of 11 open-ended questions addressing various aspects of the care situation were administered to each caregiver. The same questions were asked at baseline (within one month of the patient’s diagnosis) and four months later. Content analysis was performed to identify themes among interviews.
Main Research Variables
Patient changes, caregiver adjustments, and accessing support.
Findings
Caregivers described difficulties stemming from the patient’s tumor-related dysfunction and changes in their familial, occupational, and social roles. Support from family and friends was vital to caregivers’ emotional health, but shock and fear were evident in all interviews. Becoming subsumed in the care situation was described as enmeshment. Caregivers reported difficulty in communicating with healthcare providers. When looking at change over time, three major themes emerged: Patient Changes: The New Normal; Caregiver Adjustments; and Accessing Support.
Conclusions
Caregivers require support in handling neurologic and physical sequelae, transitioning into new roles, and avoiding becoming enmeshed in the care situation.
Interpretation
This study underlines the importance of continuing research in this area to provide the necessary interventions that will assist caregivers and provide support throughout their loved one’s disease trajectory.
doi:10.1188/11.ONF.149-155
PMCID: PMC3880557  PMID: 21356653
5.  Oncologists’ Perspectives on Concurrent Palliative Care in an NCI-designated Comprehensive Cancer Center 
Palliative & supportive care  2012;11(5):415-423.
Purpose
To understand oncology clinicians’ perspectives about the care of advanced cancer patients following the completion of the ENABLE II (Educate, Nurture, Advise, Before Life Ends) randomized clinical trial (RCT) of a concurrent oncology palliative care model.
Methods
Qualitative interview study of 35 oncology clinicians about their approach to patients with advanced cancer and the effect of the ENABLE II RCT.
Results
Oncologists believed that integrating palliative care at the time of an advanced cancer diagnosis enhanced patient care and complemented their practice. Self-assessment of their practice with advanced cancer patients comprised four themes: 1) treating the whole patient, 2) focusing on quality versus quantity of life, 3) “some patients just want to fight”, and 4) helping with transitions; timing is everything. Five themes comprised oncologists’ views on the complementary role of palliative care: 1) “refer early and often”, 2) referral challenges: “Palliative” equals hospice; “Heme patients are different”, 3) palliative care as consultants or co-managers, 4) palliative care “shares the load”, and 5) ENABLE II facilitated palliative care integration.
Conclusions
Oncologists described the RCT as holistic and complementary, and as a significant factor in adopting concurrent care as a standard of care.
doi:10.1017/S1478951512000673
PMCID: PMC3797174  PMID: 23040412
oncologist; oncology nurse practitioner; concurrent oncology palliative care; qualitative research; health care delivery
6.  Transitioning to Breast Cancer Survivorship: Perspectives of Patients, Cancer Specialists, and Primary Care Providers 
Journal of General Internal Medicine  2009;24(Suppl 2):459-466.
ABSTRACT
BACKGROUND
Limited research exists regarding views of patients, oncology specialists, and primary care providers (PCPs) concerning breast cancer survivorship care.
OBJECTIVE
To qualitatively explore the needs and priorities of breast cancer survivors, oncology specialists, and PCPs.
METHODS
Focus groups were conducted of survivors (21 in 5 groups), PCPs (15 in 2 groups), and oncology specialists (16 in 2 groups). One survivor group consisted of four African-Americans. Discussions used a semi-structured guide, were transcribed verbatim, and were analyzed qualitatively. Groups explored transitions to follow-up, communication, patient needs, and provider roles.
RESULTS
Survivors form intense relationships with specialists for reassurance and expertise. Many believed PCPs lacked necessary oncology expertise. Survivors reported psychosocial and communication issues. African-Americans cited concerns about access to care and clinical trials, as well as taboos to discussing cancer. Specialists reported that they struggle with discharging survivors due to protective relationships. PCPs were concerned about time and training to provide survivorship care and communication problems with oncologists. Written survivorship care plans were regarded by all groups as possibly helpful, but insufficient to ease the transition.
CONCLUSIONS
Breast cancer patients may experience difficulties transitioning to survivorship, including ongoing psychosocial issues. African-American patients may face additional and unique barriers to successful survivorship. Oncology specialists may have concerns about discharging cherished patients. These findings suggest a psychological component that may influence the use of written survivorship care plans. PCPs may need additional training and greater access to specialists in order to care for survivors.
doi:10.1007/s11606-009-1000-2
PMCID: PMC2763147  PMID: 19838851
7.  Nursing Practice Environment and Outcomes for Oncology Nursing 
Cancer nursing  2013;36(3):206-212.
Background
It is commonly assumed that oncology nurses experience high job-related burnout and high turnover because their work involves inherent stressors such as caring for patients with serious and often life-threatening illness.
Objectives
The objectives of this study were to examine the differences in outcomes such as job dissatisfaction and burnout between oncology nurses and medical-surgical nurses, and to identify factors that affect oncology nurse outcomes.
Methods
A secondary analysis of nurse survey data collected in 2006 including 4047 nurses from 282 hospitals in 3 states was performed; t test and χ2 test compared differences between oncology nurses and medical-surgical nurses in nurse outcomes and their assessments of nurse practice environment, as measured by the Practice Environment Scale of the Nursing Work Index. Logistic regression models estimated the effect of nurse practice environment on 4 nurse-reported outcomes: burnout, job dissatisfaction, intention to leave the current position, and perceived quality of care.
Results
Oncology nurses reported favorable practice environments and better outcomes than did medical-surgical nurses. All 4 subscales of the Practice Environment Scale of the Nursing Work Index studied were significantly associated with outcomes. Specifically, nurses who reported favorable nursing foundations for quality of care (eg, active in-service or preceptorship programs) were less likely to report burnout and leave their current position.
Conclusions
Better practice environments, including nurse foundations for quality care, can help to achieve optimal nurse outcomes.
Implications for Practice
Improving hospital practice environments holds significant potential to improve nurse well-being, retention, and quality of care. Specifically, hospitals should consider preceptor programs and continuing education and increase nurses’ participation in hospital decision making.
doi:10.1097/NCC.0b013e31825e4293
PMCID: PMC3593758  PMID: 22751101
Burnout; Job satisfaction; Nurse practice environment; Oncology nurse; Quality of care
8.  Problems After Discharge and Understanding of Communication with their PCPs Among Hospitalized Seniors: A Mixed Methods Study 
Background
Communication and coordination with primary care physicians (PCPs) is recommended to ensure safe care transitions for hospitalized older patients. Understanding patient experiences of problems after discharge can help clinical teams design more patient-centered care transitions.
Objective
To report older patients’ experiences with problems after hospital discharge and investigate whether PCPs were aware of their hospitalization
Design
Prospective mixed methods study
Setting
Single academic medical center
Patients
Hospitalized patients and PCPs
Measurements
Telephone interviews of older frail general medical patients conducted two weeks after discharge to elicit patient problems after discharge, such as obtaining medications, or follow-up appointments; and 2) perceptions of hospital physician communication with their PCP. For each patient interviewed, their PCP was faxed a survey two weeks after discharge to assess awareness of hospitalization.
Results
Forty-two percent (27) of patients reported 42 different post-discharge problems. The most frequently reported problems were difficulty with follow-up appointments or tests (12). Other reported problems included readmission and return to the Emergency Department (10), problems with medications (8), not-prepared for discharge (8), and hospital complications or questions (4). Thirty percent of PCPs were unaware of patient hospitalization. Patients were twice as likely to report a problem if their PCP was unaware of the hospitalization (31% PCP aware, vs. 67% PCP not aware; p<0.05).
Conclusion
This study suggests that many frail older patients reported problems after discharge and were twice as likely to do so when the patient’s PCP was not aware of the hospitalization. Systematic interventions to improve communication with PCPs during patient hospitalization are needed.
doi:10.1002/jhm.668
PMCID: PMC3186075  PMID: 20578045
communication; awareness; problems
9.  Patient satisfaction with inpatient care provided by the Sydney Gynecological Oncology Group 
Purpose:
Patient satisfaction with the provision of hospital oncology services can have a significant impact on their overall treatment experience.
Aims:
To assess patient satisfaction with the inpatient hospital services in the gynecological oncology setting using the IN-PATSAT32 questionnaire developed by the European Organization for Research and Treatment of Cancer (EORTC).
Methods:
A modified version of the IN-PATSAT32 questionnaire with additional 16 items was administered to 52 adult surgical inpatients admitted with the Sydney Gynecological Oncology Group. All participants were provided with an information leaflet regarding the survey and written consent obtained.
Results:
A high response rate (100%) from patients with varied social, ethnic, and educational backgrounds confirmed the acceptability of the survey. Standard of medical care provided, frequency of doctors’ visits, exchange of information with doctors, friendliness of the staff, and state of the room ranked highly (>95%) on the patient satisfaction scales. Problems were identified with ease of access to and within the hospital, quality of food, and exchange of information with other hospital staff.
Conclusions:
Overall the satisfaction with inpatient care was rated very highly in most areas. Deficiencies in certain elements of provision of medical care to the patients were identified and steps have been taken to improve upon these shortcomings.
doi:10.2147/PROM.S13897
PMCID: PMC3417917  PMID: 22915963
patient satisfaction; EORTC; IN-PATSAT32; gynecological oncology; survey
10.  What Do Oncologists Say about Chemotherapy at the Very End of Life? Results from a Semiqualitative Survey 
Journal of Palliative Medicine  2010;13(7):831-835.
Abstract
Aim
This study elicited oncologists' insights into published statistics that 20% of cancer patients receive chemotherapy within 2 weeks of death and that the median survival between chemotherapy administration and death is 37 days.
Subjects and methods
A semiqualitative survey was developed to enable respondents to provide anonymous, write-in comments on the statistics above. This survey was sent electronically on two separate occasions to oncologists in the upper midwestern United States. Qualitative methods were used to analyze data.
Results
A total of 422 oncology health-care providers were sent the survey, and 61 responded. Nine themes emerged: 1) these decisions are strongly patient-driven; 2) newer agents are driving the decision to continue with cancer treatment; 3) financial incentives on the part of the medical community explain these high rates; 4) health-care reform is necessary; 5) even a small chance of patient benefit justifies this practice; 6) this practice is detrimental to patients because it precludes the initiation of hospice services; 7) others may be prescribing in this manner, but “not us”; 8) these issues are complicated, revolve around society values, and the oncologist alone cannot claim responsibility for such high rates of chemotherapy administration; and 9) there exist barriers to end-of-life discussions.
Conclusion
Many oncologists are in fact reluctant to prescribe chemotherapy at the end of life, and the complexity of this topic underscores the potential for oncologists and palliative care providers to collaborate in an effort to provide cancer patients the best care at the very end of life.
doi:10.1089/jpm.2009.0414
PMCID: PMC2938914  PMID: 20636153
11.  Patient Experiences With Communication About Sex During and After Treatment for Cancer 
Psycho-Oncology  2011;21(6):594-601.
Objective
We studied patients’ experiences with oncology providers regarding communication about sexual issues during and after treatment for cancer.
Methods
During development of the Patient-Reported Outcomes Measurement Information System (PROMIS®) Sexual Function measure, we collected focus group and survey data on communication with oncology professionals about sexual problems. We conducted 16 focus groups with patients and survivors (n = 109) and analyzed the discussions for major themes, including experiences discussing sex during oncology visits. During testing of the PROMIS Sexual Function measure, we assessed experiences discussing sexual problems with oncology professionals (n = 819) and measured bivariate associations between asking for information from clinicians and sexual function and satisfaction with sex life.
Results
Most patients and survivors (74%) thought discussions with oncology professionals about sexual problems were important, but whether they had ever received information about sexual function from a provider varied by cancer type (23% lung, 29% breast, 39% colorectal, and 79% prostate). Those who had asked an oncology professional about sexual problems had significantly greater interest in sexual activity as well as more sexual dysfunction.
Conclusions
Sexual problems are a widespread concern among patients and survivors, but there is much variation in experiences of communication about sexual issues and many patients do not receive the information they need from their oncology providers. There are large differences in sexual function between patients who do and do not ask providers about sexual problems. Sexual health has yet to be fully integrated into oncology care, even for cancers involving sex organs.
doi:10.1002/pon.1947
PMCID: PMC3149787  PMID: 21394821
Attitude to Health; Communication; Focus Groups; Health Services Needs and Demand; Neoplasms; Physician-Patient Relations; Questionnaires; Sexuality
12.  Why differences exist? an interpretive approach to nurses’ perceptions of cancer patients’ quality of life 
BACKGROUND:
Based on the literature review that was conducted, no research study has been found in Australia to provide a detailed understanding of why nurses differ in their perceptions about cancer patients’ Quality of Life (QoL) when they communicate with patients in oncology wards.
METHODS:
This descriptive exploratory qualitative study was completed in 2007 in two major public hospitals in Adelaide, South Australia. 10 nurses from different inpatient and outpatient oncology services and a palliative setting took part in semi-structured interviews.
RESULTS:
After the data collection and analysis six main themes were identified. Differences in nurses’ perceptions about cancer patients’ QoL were discussed in the light of the sub theme “relationship and rapport”.
CONCLUSIONS:
In general, participants commented that differences existing between patients’ and nurses’ perceptions about cancer patients’ QoL were due to a poor relationship and rapport between cancer patients and their nurses. Therefore, nurses need to have a genuine interest to make an open relationship with patients in a non-judgmental way. This rapport needs to go beyond the patient and include other health care professionals as well as the patient's family.
PMCID: PMC3203291  PMID: 22039389
Cancer; quality of life; nurses; patients; qualitative research; perceptions
13.  P03.17. Utilization of Acupuncture Therapy Among Pediatric Oncology Patients at a Tertiary Care Pediatric Hospital 
Focus Area: Alleviating Pain
Acupuncture is infrequently studied in the pediatric oncology population; however, it has immense potential as a complementary cancer care modality. The aim of our analysis was to characterize the patients and utilization of acupuncture therapy among the pediatric oncology population at a tertiary care pediatric hospital. A retrospective analysis of medical records for patients between the ages of 0 and 18 years who were undergoing treatment for an oncological diagnosis and had received acupuncture therapy between January 2004 and September 2012 was conducted with sub-analysis performed of acupuncture treatments received. A total of 133 patients, comprising 3.2% of the pediatric oncology population at our institution, utilized acupuncture therapy during the years 2004 to 2012. A cumulative 523 acupuncture treatments were provided in both the outpatient and inpatient settings. The majority of patients receiving acupuncture were in their teenage years and received between 1 and 5 treatments. While referrals were mainly received for a pain indication or nausea and vomiting, acupuncture treatments provided addressed a wide variety of patients' complaints. Acupuncture use among the pediatric oncology population is relatively low; however, acupuncture appears to be well tolerated, perceived as beneficial, and without any serious adverse events in this population. These findings help to identify optimal ways in which acupuncture services can be offered clinically to this unique population in the future. Acupuncture therapy demonstrated potential as a beneficial complementary cancer care modality for a wide variety of complaints and cancer treatment-related side effects in patients with varying ages and cancer diagnoses. Further research is warranted to explore evidence-based data with regard to the safety and efficacy of acupuncture use among pediatric oncology patients and to determine its impact on quality of life and treatment outcomes including impact on cancer treatment–related side effects.
doi:10.7453/gahmj.2013.097CP.P03.17
PMCID: PMC3875033
14.  A GP caregiver needs toolkit versus usual care in the management of the needs of caregivers of patients with advanced cancer: a randomized controlled trial 
Trials  2010;11:115.
Background
Caring for a person with progressive cancer creates challenges for caregivers. However the needs of caregivers are often not assessed or recognised by health care providers. Research is also lacking in this area, with little knowledge relating to effective strategies to address the specific needs of caregivers. This paper outlines a study protocol aimed at developing and evaluating the effectiveness of a general practice-based intervention to better meet the needs of caregivers of patients with advanced cancer.
Methods/Design
Two hundred and sixty caregivers will be randomised into each of two arms of the intervention (520 participants in total) through patients with advanced cancer attending medical and radiation oncology outpatient clinics at two tertiary hospital sites. Consenting caregivers will be followed up for six months, and telephone surveyed at baseline, 1, 3 and 6 months following their entry into the study or until the patient's death, whichever occurs first. Assessment and management of the unmet needs of caregivers in the intervention arm will be facilitated through a specifically developed general practice-based strategy; caregivers in the control group will receive usual care. Qualitative interviews will be conducted with a sample of up to 20 caregivers and 10 GPs at the conclusion of their participation, to explore their views regarding the usefulness of the intervention.
Discussion
This study will determine whether systematic assessment of caregiver needs supported by caregiver-specific information for General Practitioners is effective in alleviating the unmet needs experienced by caregivers caring for patients with advanced cancer.
Trial registration number
ISRCTN: ISRCTN43614355
doi:10.1186/1745-6215-11-115
PMCID: PMC3009964  PMID: 21114863
15.  A Qualitative Analysis of an Advanced Practice Nurse–Directed Transitional Care Model Intervention 
The Gerontologist  2011;52(3):394-407.
Purpose:
The purpose of this study was to describe barriers and facilitators to implementing a transitional care intervention for cognitively impaired older adults and their caregivers lead by advanced practice nurses (APNs).
Design and Methods:
APNs implemented an evidence-based protocol to optimize transitions from hospital to home. An exploratory, qualitative directed content analysis examined 15 narrative case summaries written by APNs and fieldnotes from biweekly case conferences.
Results:
Three central themes emerged: patients and caregivers having the necessary information and knowledge, care coordination, and the caregiver experience. An additional category was also identified, APNs going above and beyond.
Implications:
APNs implemented individualized approaches and provided care that exceeds the type of care typically staffed and reimbursed in the American health care system by applying a Transitional Care Model, advanced clinical judgment, and doing whatever was necessary to prevent negative outcomes. Reimbursement reform as well as more formalized support systems and resources are necessary for APNs to consistently provide such care to patients and their caregivers during this vulnerable time of transition.
doi:10.1093/geront/gnr078
PMCID: PMC3342512  PMID: 21908805
Care coordination; Continuum of care; Nursing studies; Qualitative research methods
16.  Patients' perceptions of safety and quality of maternity clinical handover 
Background
Maternity clinical handover serves to address the gaps in knowledge existing when transitions between individuals or groups of clinicians occur throughout the antenatal, intra-partum and postnatal period. There are limited published studies on maternity handover and a paucity of information about patients' perceptions of the same. This paper reports postnatal patients' perceptions of how maternity handover contributes to the quality and safety of maternity care.
Methods
This paper reports on a mixed-methods study consisting of qualitative interviews and quantitative medical record analysis. Thirty English-speaking postnatal patients who gave birth at an Australian tertiary maternity hospital participated in a semi-structured interview prior to discharge from hospital. Interview data were coded thematically using the constant comparative method and managed via NVivo software; this data set was supplemented by medical record data analysed using STATA.
Results
Almost half of the women were aware of a handover process. Clinician awareness of patient information was seen as evidence that handover had taken place and was seen as representing positive aspects of teamwork, care and communication by participants, all important factors in the perception of quality health care. Collaborative cross-checking, including the use of cognitive artefacts such as hand held antenatal records and patient-authored birth plans, and the involvement of patients and their support people in handover were behaviours described by participants to be protective mechanisms that enhanced quality and safety of care. These human factors also facilitated team situational awareness (TSA), shared decision making and patient motivation in labour.
Conclusions
This study illustrates that many patients are aware of handover processes. For some patients, evidence of handover, through clinician awareness of information, represented positive aspects of teamwork, care and communication.
Cross-checking and cognitive artefacts were observed to support handover. Patient-authored birth plans were described by some to enhance the quality and safety of the handover by providing a 'voice' to the patient in this process. This was a novel and potentially important perspective.
Future research involving patients and their support people in supporting and evaluating handover should be considered.
doi:10.1186/1471-2393-11-58
PMCID: PMC3167750  PMID: 21827711
17.  The Patient Care Circle: A Descriptive Framework for Understanding Care Transitions 
Background
Reducing hospital readmissions depends on ensuring safe care transitions, which requires a better understanding of the challenges experienced by key stakeholders.
Objective
Develop a descriptive framework illustrating the interconnected roles of patients, providers and caregivers in relation to readmissions.
Design
Multi-method qualitative study with four focus groups and 43 semi-structured interviews. Multiple perspectives were included to increase the trustworthiness (internal validity) and transferability (external validity) of the results. Data were analyzed using Grounded Theory to generate themes associated with readmission.
Setting/Patients
General medicine patients with same-site 30-day readmissions, their family members, and multiple care providers at a large urban academic medical center.
Results
A keynote generated from the multi-perspective responses was that care transitions were optimized by a well-coordinated multidiscipline support system, described as the Patient Care Circle. In addition, issues pertaining to readmissions were identified and classified into five main themes emphasizing the necessity of a coordinated support network: (1) Teamwork; (2) Health systems navigation and management; (3) Illness severity and health needs; (4) Psychosocial stability; (5) Medications.
Conclusion
A well-coordinated collaborative Patient Care Circle is fundamental to ensuring safe care transitions.
doi:10.1002/jhm.2084
PMCID: PMC4030373  PMID: 24124032
18.  Integrative practices of Canadian oncology health professionals 
Current Oncology  2008;15(Suppl 2):s110.es87-s110.es91.
Objective
Cancer patients are increasingly known to use complementary medicine (cam) during conventional treatment, but data are limited on how Canadian oncology health professionals attempt to assist patients with their use of cam in the context of conventional cancer care. As part of a larger qualitative study assessing the perceptions of Canadian oncology health professionals regarding integrated breast cancer care, we undertook an exploration of current integrative practices of oncology health professionals.
Design
Using an interpretive description research design and a purposive sampling, we conducted a series of in-depth qualitative interviews with various oncology health professionals recruited from provincial cancer agencies, hospitals, integrative clinics, and private practice settings in four Canadian cities: Vancouver, Winnipeg, Montreal, and Halifax. A total of 16 oncology health professionals participated, including medical and radiation oncologists, nurses, and pharmacists.
Results
Findings highlighted two main strategies used by oncology health professionals to create a more integrative approach for cancer patients: acting as an integrative care guide, and collaborating with other health professionals.
Conclusions
Although few clear standards of practice or guidance material were in place within their organizational settings, health professionals discussed some integrative roles that they had adopted, depending on interest, knowledge, and skills, in supporting patients with cam decisions. Given that cancer patients report that they want to be able to confer with their conventional health professionals, particularly their oncologists, about their cam use, health professionals who elect to adopt integrative practices are likely offering patients much-welcomed support.
PMCID: PMC2528555  PMID: 18769573
Oncology health professionals; integrative cancer care; qualitative research; complementary therapies
19.  Care transitions for frail, older people from acute hospital wards within an integrated healthcare system in England: a qualitative case study 
Introduction
Frail older people experience frequent care transitions and an integrated healthcare system could reduce barriers to transitions between different settings. The study aimed to investigate care transitions of frail older people from acute hospital wards to community healthcare or community hospital wards, within a system that had vertically integrated acute hospital and community healthcare services.
Theory and methods
The research design was a multimethod, qualitative case study of one healthcare system in England; four acute hospital wards and two community hospital wards were studied in depth. The data were collected through: interviews with key staff (n = 17); focus groups (n = 9) with ward staff (n = 36); interviews with frail older people (n = 4). The data were analysed using the framework approach.
Findings
Three themes are presented: Care transitions within a vertically integrated healthcare system, Interprofessional communication and relationships; Patient and family involvement in care transitions.
Discussion and conclusions
A vertically integrated healthcare system supported care transitions from acute hospital wards through removal of organisational boundaries. However, boundaries between staff in different settings remained a barrier to transitions, as did capacity issues in community healthcare and social care. Staff in acute and community settings need opportunities to gain better understanding of each other's roles and build relationships and trust.
PMCID: PMC4027893  PMID: 24868193
vertical integration; integrated care; frail older people; care transitions; acute hospital wards; community healthcare
20.  A Qualitative Study of Oncologists' Approaches to End-of-Life Care 
Journal of Palliative Medicine  2008;11(6):893-906.
Abstract
Purpose
To understand how oncologists provide care at the end of life, the emotions they experience in the provision of this care, and how caring for dying patients may impact job satisfaction and burnout.
Participants and methods
A face-to-face survey and in-depth semistructured interview of 18 academic oncologists who were asked to describe the most recent inpatient death on the medical oncology service. Physicians were asked to describe the details of the patient death, their involvement with the care of the patient, the types and sequence of their emotional reactions, and their methods of coping. Grounded theory qualitative methods were utilized in the analysis of the transcripts.
Results
Physicians, who viewed their physician role as encompassing both biomedical and psychosocial aspects of care, reported a clear method of communication about end-of-life (EOL) care, and an ability to positively influence patient and family coping with and acceptance of the dying process. These physicians described communication as a process, made recommendations to the patient using an individualized approach, and viewed the provision of effective EOL care as very satisfying. In contrast, participants who described primarily a biomedical role reported a more distant relationship with the patient, a sense of failure at not being able to alter the course of the disease, and an absence of collegial support. In their descriptions of communication encounters with patients and families, these physicians did not seem to feel they could impact patients' coping with and acceptance of death and made few recommendations about EOL treatment options.
Conclusion
Physicians' who viewed EOL care as an important role described communicating with dying patients as a process and reported increased job satisfaction. Further research is necessary to determine if educational interventions to improve physician EOL communication skills could improve physician job satisfaction and decrease burnout.
doi:10.1089/jpm.2007.2480
PMCID: PMC2998030  PMID: 18715182
21.  Integrated transitional care: patient, informal caregiver and health care provider perspectives on care transitions for older persons with hip fracture 
Introduction
Complex older adults, such as those with hip fracture, frequently require care from multiple professionals across a variety of settings. Integrated care both between providers and across settings is important to ensure care quality and patient safety. The purpose of this study was to determine the core factors related to poorly integrated care when hip fracture patients transition between care settings.
Methods
A qualitative, focused ethnographic approach was used to guide data collection and analysis. Patients, their informal caregivers and health care providers were interviewed and observed at each care transition. A total of 45 individual interviews were conducted. Interview transcripts and field notes were coded and analysed to uncover emerging themes in the data.
Results
Four factors related to poorly integrated transitional care were identified: confusion with communication about care, unclear roles and responsibilities, diluted personal ownership over care, and role strain due to system constraints.
Conclusions
Our research supports a broader notion of collaborative practice that extends beyond specific care settings and includes an appropriate, informed role for patients and informal caregivers. This research can help guide system-level and setting-specific interventions designed to promote high-quality, patient-centred care during care transitions.
PMCID: PMC3564427
care transitions; integrated care; musculoskeletal disorders; family-centred care; patient-centred care
22.  Integrated transitional care: patient, informal caregiver and health care provider perspectives on care transitions for older persons with hip fracture 
Introduction
Complex older adults, such as those with hip fracture, frequently require care from multiple professionals across a variety of settings. Integrated care both between providers and across settings is important to ensure care quality and patient safety. The purpose of this study was to determine the core factors related to poorly integrated care when hip fracture patients transition between care settings.
Methods
A qualitative, focused ethnographic approach was used to guide data collection and analysis. Patients, their informal caregivers and health care providers were interviewed and observed at each care transition. A total of 45 individual interviews were conducted. Interview transcripts and field notes were coded and analysed to uncover emerging themes in the data.
Results
Four factors related to poorly integrated transitional care were identified: confusion with communication about care, unclear roles and responsibilities, diluted personal ownership over care, and role strain due to system constraints.
Conclusions
Our research supports a broader notion of collaborative practice that extends beyond specific care settings and includes an appropriate, informed role for patients and informal caregivers. This research can help guide system-level and setting-specific interventions designed to promote high-quality, patient-centred care during care transitions.
PMCID: PMC3429139  PMID: 22977426
care transitions; integrated care; musculoskeletal disorders; family-centred care; patient-centred care
23.  Factors Influencing Communication Between the Patients with Cancer and their Nurses in Oncology Wards 
Aims:
The purpose of this study was to demonstrate the factors influencing nurse-patient communication in cancer care in Iran.
Materials and Methods:
This study was conducted with a qualitative conventional content analysis approach in oncology wards of hospitals in Tabriz. Data was collected through purposive sampling by semi-structured deep interviews with nine patients, three family members and five nurses and analyzed simultaneously. Robustness of data analysis was evaluated by the participants and external control.
Results:
The main theme of the research emerged as “three-factor effects” that demonstrates all the factors related to the patient, nurse, and the organization and includes three categories of “Patient as the center of communication”, “Nurse as a human factor”, and “Organizational structures”. The first category consists of two sub-categories of “Imposed changes by the disease” and the “patient's particular characteristics”. The second category includes sub-categories of “sense of vulnerability” and “perception of professional self: Pre-requisite of patient-centered communication”. The third category consists of the sub-categories of “workload and time imbalance”, “lack of supervision”, and “impose duties in context of neglecting nurse and patient needs”. Characteristics of the patients, nurses, and care environment seemed to be the influential factors on the communication.
Conclusions:
In order to communicate with cancer patients effectively, changes in philosophy and culture of the care environment are essential. Nurses must receive proper trainings which meet their needs and which focus on holistic and patient-centered approach.
doi:10.4103/0973-1075.125549
PMCID: PMC3931236  PMID: 24600177
Cancer; Effective factors; Nurse-patient communication; Oncology
24.  The key actor: a qualitative study of patient participation in the handover process in Europe 
BMJ quality & safety  2012;21(Suppl_1):i89-i96.
Background
Patient safety experts have postulated that increasing patient participation in communications during patient handovers will improve the quality of patient transitions, and that this may reduce hospital readmissions. Choosing strategies that enhance patient safety through improved handovers requires better understanding of patient experiences and preferences for participation.
Objective
The aim of this paper is to explore the patients’ experiences and perspectives related to the handovers between their primary care providers and the inpatient hospital.
Methods
A qualitative secondary analysis was performed, based on individual and focus group patient interviews with 90 patients in five European countries.
Results
The analysis revealed three themes: patient positioning in the handover process; prerequisites for patient participation and patient preferences for the handover process. Patients’ participation ranged from being the key actor, to sharing the responsibility with healthcare professional(s), to being passive participants. For active participation patients required both personal and social resources as well as prerequisites such as information and respect. Some patients preferred to be the key actor in charge; others preferred their healthcare professionals to be the key actors in the handover.
Conclusions
Patients’ participation is related to the healthcare system, the activity of healthcare professionals’ and patients’ capacity for participation. Patients prefer a handover process where the responsibility is clear and unambiguous. Healthcare organisations need a clear and well-considered system of responsibility for handover processes, that takes into account the individual patient's need of clarity, and support in relation to his/hers own recourses.
doi:10.1136/bmjqs-2012-001171
PMCID: PMC3551200  PMID: 23112290
Patient-centred care; Transitions in care; Qualitative research
25.  Clinicians’ views on improving inter-organizational care transitions 
Background
Patients with complex health conditions frequently require care from multiple providers and are particularly vulnerable to poorly executed transitions from one healthcare setting to another. Poorly executed care transitions can result in negative patient outcomes (e.g. medication errors, delays in treatment) and increased healthcare spending due to re-hospitalization or emergency room visits by patients. Little is known about care transitions from acute care to complex continuing care and rehabilitation settings. Thus, a qualitative study was undertaken to explore clinicians’ perceptions of strategies aimed at improving patient care transitions from acute care hospitals to complex continuing care and rehabilitation healthcare organizations.
Methods
A qualitative study using semi-structured interviews was conducted with clinicians employed at two selected healthcare facilities: an acute care hospital and a complex continuing care/rehabilitation organization, respectively. Analysis of the transcripts involved the creation of a coding schema using the content analyses outlined by Ryan and Bernard. In total, 31 interviews were conducted with clinicians at the participating study sites.
Results
Three themes emerged from the data to delineate what study participants described as strategies to ensure quality inter-organizational transitions of patients transferred from acute care to the complex continuing care and rehabilitation hospital. These themes are: 1) communicating more effectively; 2) being vigilant around the patients’ readiness for transfer and care needs; and 3) documenting more accurately and completely in the patient transfer record.
Conclusion
Our study provides insights from the perspectives of multiple clinicians that have important implications for health care leaders and clinicians in their efforts to enhance inter-organizational care transitions. Of particular importance is the need to have a collective and collaborative approach amongst clinicians during the inter-organizational care transition process. Study findings also suggest that the written patient transfer record needs to be augmented with a verbal report whereby the receiving clinician has an opportunity to discuss with a clinician from the acute care hospital the patient’s status on discharge and plan of care. Integral to future research efforts is designing and testing out interventions to optimize inter-organizational care transitions and feedback loops for complex medical patients.
doi:10.1186/1472-6963-13-289
PMCID: PMC3751015  PMID: 23899326
Care transitions; Inter-organizational; Orthopedic patients

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