A Sabbatical Journey of Discovery: Aspects of Nursing Care Delivery along the Continuum of Service
This is the third in a series of reports to share key learnings from my 2005 sabbatical, when I took a three-month journey through Scandinavia, Western Europe, Ireland and the United Kingdom to observe innovation in nursing services delivery. The focus of this report is nursing care delivery along the continuum of service. All the countries I visited were moving towards the provision of networked services along the continuum of care.
Denmark, Ireland and England have established oncology nurse coordinator roles that follow patients along the service continuum. In Copenhagen, a cancer pathway based on best practices was being developed.
In Dublin, a database was in place encompassing all information needed to track an individual cancer patient's journey through the system. Quality-of-life surveys are utilized to measure outcomes for oncology patients, and patient satisfaction tools have been developed specifically for cancer care.
The National Health Service in England has developed a cancer plan and oncology care networks that link the whole patient journey. The Healthcare Trusts, responsible for management of healthcare services, are required to meet targets that are based on national guidelines from the NHS cancer plan. Oncology patient pathways are used across networks of care to achieve these targets. Nursing-led Rectal Bleed clinics and a nursing-led Bowel Screening program have been implemented. Home- or community-based chemotherapy is also in place. Cancer patient satisfaction surveys have been developed that are geared to the particular challenges of living with cancer as a chronic disease and managing symptoms.
Palliative and end-of-life care was also well represented on the continuum of care. Patient-directed palliative services design is in place in the Netherlands. Multidisciplinary hospice facilities exist in regional networks both in the Netherlands and in Belgium.
France has initiated an interdisciplinary palliative team approach to creating a cultural acceptance of palliative care in hospitals. An emergency palliative care team that can be sent from the hospital into the home has also been developed. A new four-bed palliative care unit was in development for patients in the last week of life. All palliative care and oncology nurses in France are required to have relationship competence.
Euthanasia is a patient-led service in the Netherlands. Upon a patient's request, two independent medical opinions are required to support euthanasia. Criteria include verification that the condition is palliative, and overwhelming symptoms such as choking, suffocation or intractable pain. If the criteria are met, the patient determines the location and time to receive an initial intravenous injection to induce sleep, followed by a lethal dose of intravenous medication. Often, patients have family and friends with them in a setting of their choosing.
Interprofessional Web-based, pre-operative assessment modules, a CD and a book have been developed in England and are offered in credit courses to health professionals. Regional interdisciplinary pre-operative assessment units are being implemented in England, where patients for elective surgery receive an interdisciplinary assessment to determine their fitness for surgery. In some cases alternative approaches to care, such as rehabilitation, are initiated.
In Denmark, Dr. Henrik Kehlet has promoted minimum intervention and risk-free surgical approaches that include rigorous pain management protocols. Multidisciplinary preparation of patients before admission helps them deal with post-operative pain. In Copenhagen, Dr. Lars Heslet has advanced the use of complementary therapies, such as music, to reduce pain for ICU patients.
In Edinburgh, Dr. Ian Power has demonstrated great success with physician engagement in the advancement of best practices in pain. He has established a pain executive team and developed distance learning programs for health professionals in Scotland.
In England, 3,000 community matrons are being put in place to manage the care of the 5% of patients who account for 40% of healthcare system costs. These nurses will oversee the care of these patients and move with them throughout the continuum of service.
Patients have taken charge of managing their own care in Germany through the development of shared flats with a contract for community nursing services to ensure that they can remain independent in the community.
Researchers in the Netherlands believe that networks are the path to facilitating integration across systems. They are also working towards performance contracts that would provide greater compensation for services that are based on best practices.
As you can see, our colleagues abroad are advancing interprofessional service delivery partnered with patients along the continuum of service. Canadians can learn from these approaches to advance our own work in regionalized systems or, in Ontario, Local Health Integration Networks. These ideas provide opportunities to test similar programs or to advance initiatives already underway by improving coordination, integration, transition, continuity and access to services.
I look forward to sharing other key learnings in future reports.
About the Author
Vice President, Professional Affairs and Chief Nurse Executive
University Health Network, Toronto, ON
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