Community Nursing Palliative Care Snapshot Survey

Summary of results Rounds 1, 2 & 3

BackgroundThe Better Access to Palliative Care program (BAPC) aims to enhance access to community based palliative care and to strengthen existing palliative care services. Over the past 2 years the DHHS BAPC project has been delivering a range of community, service and system level palliative care initiatives. Throughout the BAPC project considerable feedback and information has been received about the role of community nursing in delivering palliative care services. In response to this feedback, we are seeking to understand the extent to which Tasmanian Health Service (THS), particularly primary care providers, are engaged in delivering community palliative care.

At this time there is no data available about palliative care services provided by Community Nursing. This makes it difficult to demonstrate the impact of community nursing in the area of community palliative care and to plan for service enhancements. As a result the BAPC project conducted a series of 3 snapshot surveys to establish an estimate of this contribution.

The palliative care snapshot survey was an opportunity to gather quantitative information about the palliative care services being delivered and to estimate demand for palliative care services through Community Nursing. The statewide snapshot was conducted over three separate occasions, for a period of 7 days.

MethodsParticipantsContact email addresses for community nurses were provided by managers from across the state. A distribution list was developed, with nurses to be contacted daily over a 7 day period. Community Nurses were emailed daily and provided with a direct link to the Survey Monkey survey. The survey included 6 questions enquiring about the location of service, number of patients seen, time providing palliative care and demographic data about the client. The survey had some minor adjustments with each round, firstly to improve functionality for analysis and secondly, to add clarity to questions.

The survey was distributed to all community nurses on the mailing list on the three occasions of the survey.

Round 1 – 16th November, 2015 (23rd November Southern regions)Round 2 – 14th December, 2015Round 3 – 1st February, 2016

ResultsThe average number of responses across Community Nursing regions was similar across surveys, but with an increase in Round 2 and reduction in Round 3.

Figure 1

Round 1 Round 2 Round 3150

200

250

300

350

400

296320

272

349 360339

Number of responses per survey (Rounds 1-3)

Worked

Total re-sponses

Num

ber

Across the 3 rounds, 80-90% of community nurses worked on the day they completed the survey. In Round 3, there were an increased number of participants who had not worked that day (n=67, 20%) and who were excluded in the analysis.

Figure 2

Round 1 Round 2 Round 3 Average50525456586062

59

54

6058

Cared for patient with palliative care needs today %

Yes%

Across the 3 rounds there was a range of 54%-59% of nurses who reported having cared for patients with palliative care needs, with a slight drop in Round 2. On average, 58% of participants had cared for a patient with palliative care needs during their nursing shift.

Figure 3

Round 1 Round 2 Round 3295300305310315320325

303

312

319

Palliative patients cared for today (Rounds 1-3)

Num

ber

The number of patients identified as having palliative needs increased across the three surveys rounds.Figure 4

Round 1 Round 2 Round 3280285290295300305310315

292

303

312

Time caring for palliative patients (Rounds 1-3)

Hou

rs

The time spent providing care to palliative patients increased across the three survey rounds.

Figure 5

Round 1 Round 2 Round 3050

100150200250300

82 71 57

207 221252

3

Age group of palliative patients (Rounds 1-3)

Aged 0-18Aged 19-64Aged 65+

Num

ber

The majority of patients were aged over 65 (68% Round 1, 71% Round 2, and 79% Round 3). The number of patients aged over 65 increased across surveys, with those aged 19-64 reducing in each round.

Figure 6

Round 1 Round 2 Round 3100110120130140150160170180

128 132

160170

162152

Gender of palliative patients seen (rounds 1-3)

MalesFemales

Num

ber

There was a decrease in female patients over the 3 rounds (170-152), and a large increase in the number of male patients (128 to 160).

Figure 7

Round 1 Round 2 Round 3260270280290300310320330

303312

319

296

320

272

Comparison of valid responses with number of palliative patients (Rounds 1-3)

Number of pa-tients seenNurses who worked today

Num

ber

The number of participants who responded that they worked increased in Round 2, but fell sharply in Round 3. The number of palliative patients provided care increased consistently across the 3 rounds.

Figure 8

Round 1 Round 2 Round 3260270280290300310320330

292303

312

296

320

272

Comparison of valid responses with hours spent caring for palliative patients

Hours provid-ing care to palliative pa-tientsNurse who worked today

No.

There was a consistent increase in the hours reported caring for palliative patients across the 3 rounds.

Figure 9

Round 1 Round 2 Round 3 Average152001540015600158001600016200164001660016800

15804

16279

16644

16242.3333333333

Annual estimate of hours of care

Hou

rs

The estimated episodes of palliative care provided per year (based upon these three snapshot surveys) would be 16,242. As an episode of care is on average 1 hour per patient, this is the equivalent of 16,242 hours annually; or 2137 (7.6 hour) days.

DiscussionThe snapshot survey was a successful attempt to gather baseline information about the delivery of palliative care by community nurses. There was an increase in nurse participation in the second round which dropped off again in Round 3. In Round 3, an increased number of participants commenced the survey despite not having worked, which might suggest that the survey process had been embraced by many Community Nurses by this round. Participation rates across the three rounds indicate that there was a reasonable response rate from which to draw some conclusions.

The format of the survey changed slightly with each round and may account for an increased number of reported palliative care episodes. In round two, changes were made to:

a) The format of the survey – refining questions and functionality of the surveyb) Instructions on how to complete the surveyc) Specify palliative patients in questions related to gender and age

In Round three, additional information was added to elicit information about indirect care of patients. Feedback had indicated that indirect care such as administration and telephone calls were not being factored into reporting by some nurses.

Figures 6 and 7 demonstrate that despite fewer numbers of responses in Round 3, there was an increase in the number of palliative patients and time recorded. This could be accounted for by a change in understanding of the definition of palliative by participants, and also the addition of “including indirect care e.g. phone calls” to the survey questions.

The estimated annual delivery of palliative care is based on an average of these three survey rounds, and is likely to be an underestimate of actual palliative care delivery. (See figure 9)

Limitations of the surveyThe limitations of this survey include:

a) Unknown response rateb) Improvements to survey with each iterationc) Individual interpretation and reporting of palliative patient cared) Short period of reporting

An accurate response rate for this survey is not available as actual hours worked (and nursing shifts) over these three rounds has not been sought. However, it can be estimated that not all nurses completed the survey each day they worked and therefore figures are likely to be under-reported.

Iterative changes to the structure of questions and the survey itself means that there is likely to be inconsistencies between rounds. The action learning process of adjusting the survey with each round; resulting in improved reporting in Round 3 would suggest that the final survey produced the most accurate reporting.

Definitions of palliative care would be subject to the interpretation and understanding of an individual participant. While the introduction page suggested community nurses use the “surprise” question to assess their patients as palliative; figures would suggest that this was not applied across the board. Similarly, applying a definition to what types of work should have been included in the survey would have potentially increased the reporting. This amendment occurred in Round 3.

The survey is only for a short time period and therefore changes in palliative patient numbers may mean that weeks of higher demand are easily missed in a snapshot survey. An extended survey period over a month, or alternatively, regular reporting would capture these peaks in demand more accurately.

Conclusion

The results of this survey have demonstrated that Community Nursing Services play a significant role in the delivery of palliative care within the community. This is consistent with h@H outcomes; with the majority of brokered services being personal care and domestic assistance rather than nursing care.

Initial estimates demonstrate that community nurses deliver approximately 16,242 hours of care or 2,137 full time days annually. Effective reporting of time and consistent definitions of palliative care would assist in providing a more accurate and complete picture of the work of community nurses in delivering community palliative care.

Recommendations:The results of this series of snapshot surveys have enabled the DHHS BAPC project to develop an initial understanding of the role of Community Nursing in palliative care. BAPC recommends that another survey be conducted in March, incorporating the learnings of the first three rounds and building on the findings achieved to date.