Sally Boa

Using the WHO-ICF with Talking Mats to Enable Adults with Long-term Communication Difficulties to Participate in Goal Setting

The World Health Organization International Classification of Functioning, Disability and Health (WHO-ICF) provides a framework that helps rehabilitation staff to take a holistic view of the patient. However, it is used predominantly by professionals rather than by active participation on behalf of the person with the disability. In addition, the language used within the framework can be difficult for patients to understand. In order to address these issues the Activities and Participation section of the ICF has been adapted by using graphic symbols. It has been used in conjunction with Talking Mats™1, a low-tech communication framework, to help adults with long-term conditions participate in goal setting. This paper describes how this was done and provides examples from clinical practice. The paper discusses how this combined framework can empower people with communication difficulties and long-term conditions to become active participants in the rehabilitation process by identifying their own goals, indicating changing priorities and tracking their progress.

Goal setting in palliative care: A structured review

Abstract Background Palliative care and rehabilitation both aim to support patients to live as actively as possible. Goal setting has been identified in health policy and clinical guidelines as a mechanism to achieve this. While goal setting is well established in traditional rehabilitation, it is unclear how it should be implemented within palliative care where people are faced with diminishing abilities. Aim To identify and synthesize published literature regarding goal setting in palliative care. Method Electronic searches were carried out on MEDLINE, PSYCHINFO, EMBASE, CINAHL, ASSIA, and Google Scholar databases between November 2010 and January 2011. Papers were included if they focused on patient-centred goal setting in palliative care. No restrictions were placed on study design or type of paper. Papers were classified according to the type and design and research papers were quality appraised. Papers were read and analysed using framework analysis. Findings Sixteen papers met the inclusion criteria. Three themes were identified: 1. Definitions, process, and functions of goal setting;2. The challenges of delivering goal setting;3. Theories underpinning goal setting. Conclusions Goal setting is recognized as an important component of patient-centred palliative care, but there is no agreement regarding ‘best practice’ and clinicians face particular challenges when trying to set goals with patients in this context. Little attention has been paid to developing a robust, theory-based approach to goal setting in this setting. Hope theory and theories of how people adapt to life-threatening illness could inform the process of goal setting in palliative care.

89 End of life care and cognitive impairment: a quality improvement study

Background A hospice retrospective in-patient case notes review explored care provision at the end of life, mapped against the four key principles in the Scottish Government guidance. Most patients had documentation of informative, sensitive and timely discussions about dying, and exploration of their fears, concerns, goals, wishes, and social, spiritual and psychological needs. However, this was less likely if patients had cognitive impairment. Aim To understand from staff caring for patients with cognitive impairment in a hospice in-patient unit, what prevents them from exploring and documenting their wider holistic needs. Methodology A qualitative study was undertaken, interviewing in-patient hospice medical and nursing staff, using the 5 Whys tool. Results were analysed using a framework analysis approach. Results Fifteen staff members were interviewed – five doctors, five registered general nurses and five healthcare assistants. Themes that emerged included: confidence and skills when communicating with cognitively impaired patients and their informal carers; the importance of familiarity and developing relationships over time; that physical care tended to take priority over time spent exploring issues especially when time was limited. Reasons for not exploring and documenting were common for all staff groups. Conclusions and recommendations The results were presented to the wider hospice team who made suggestions for change. These included: offering additional staff education and training in communicating with cognitively impaired people; proactively consulting informal carers to gain a deeper understanding of patients‘ needs; the use of a person-centred document for informal carers to complete with patients if able, that encouraged identification and exploration of psycho-social concerns; using routine handovers to highlight when these areas had not been addressed. A working group will be formed to implement and test changes to practice as part of the quality improvement in this area.

P-12 Talking mats: an approach to support conversations in a hospice setting

Background Professionals who work in palliative care settings strive to provide person centred care (NICE, 2011). Finding out what is important to patients and families is core to this (Henry, 2015). People who use hospices often have specific difficulties communicating their thoughts and feelings because of advanced illness and emotional factors. Talking Mats is a visual framework which has been shown as an effective method to enable people to express their views, especially when their ability to communicate is compromised, for example because of cognitive, physical or emotional difficulties (Murphy et al., 2013; Murphy & Boa, 2012; Murphy, 2009). Aims We aimed to introduce and use Talking Mats in a hospice setting and to develop a symbol set to support conversations relating to Advance Care Planning (ACP). Methods Sixteen staff from the multidisciplinary team were trained to use Talking Mats and successfully used it with patients in the hospice. A sub-group of staff attended a workshop to discuss the potential use of Talking Mats to support conversations relating to ACP. Topics and options were agreed. These were then presented to a wider forum of staff from another Hospice for validation and checking. Three main topics to support ACP conversations were identified: Affairs; Care and Personal Values and are currently being trialled with a range of patients in the hospice setting. Results Staff trained in the use of Talking Mats found that they could use it with a range of patients for a variety of purposes: getting to know someone; identifying goals; discharge planning and enabling ACP discussions. Conclusion Talking Mats can be used by trained staff in a hospice setting to support people to express their views and help them plan for the end of life.

P-119 Development, implementation and evaluation of a theory based goal setting framework in a hospice

Background Rehabilitation and goal setting can support one of the key principles of palliative care, to help people live actively until they die. Until recently, no theory based practice framework has existed. A framework for goal setting in palliative care (G-AP-PC) was therefore developed and implemented systematically, through 4 phases, in one hospice. Aims To develop and implement a theory based goal setting framework to guide and support patient-centred goal setting in practice. Methods Phase 1: Gathering information about goal setting practice through a structured literature review and observation of practice in one hospice. Phase 2: Identifying and applying theories which could underpin a goal setting framework and support patient-centred goal setting. Phase 3: Use of a participatory approach, based on Normalisation Process Theory (NPT) to develop and implement a framework for goal setting. Phase 4: Evaluation of the impact of implementing GAP-PC, using interviews (patients/professionals), a questionnaire (professionals) and case note analysis. Results G-AP PC was successfully implemented. It helped professionals to work as a team; shift their attention from a solely symptoms/problems/risk based approach to focusing on patients’ goals; act on what patients wanted to achieve, within short timescales, with documentaryevidence of practice. Patients reported that use of G-AP PC allowed them to focus on goals that were important to them. There was also evidence that goal setting helped increase their motivation and self-efficacy. Conclusions and application to hospice practice Use of an explicit, theory based goal setting framework provides a mechanism for ensuring that individual, patient centred goals are established, documented and reviewed. It also helps professionals focus on what is important to patients. Following successful implementation in one ward, G-AP PC is now being used throughout the hospice to support people to live until they die. Future research will explore the potential application of this framework to other palliative care settings.

Goal setting in palliative care: a structured literature review

Objectives To identify and synthesise existing literature on goal setting in palliative care, with a view to identifying a conceptual framework to underpin the process. Methods Searches were conducted using MEDLINE, PSYCHINFO, EMBASE, CINAHL, ASSIA and Google Scholar data bases between November 2010 and January 2011. Additional articles were located by screening the reference lists of those which were included. Papers were included if they focused on patient centred goal setting for patients with palliative care needs. Included papers were categorised according to type (quantitative, qualitative, mixed methods, literature review, conceptual, opinion or practice based). Research papers were quality appraised. Critical interpretive synthesis was used to analyse and synthesise data. Results 16 papers about goal setting in palliative care were included (four quantitative, one mixed methods, three qualitative, one literature review, three conceptual, one opinion based and three practice based). Research papers varied in quality and primary focus. There was no clear definition of goal setting. Three themes emerged: what goal setting is; challenges and factors that affect goal setting and emerging theory/conceptual underpinning of goal setting. Conclusions Patient centred goal setting is recognised as an important component of palliative care and is described as beneficial for patients, families and professionals. It is proposed as a method of ensuring that care is patient led, giving patients a sense of control and bringing meaning. Goal setting appears to be slightly different in palliative care as compared to general rehabilitation settings, primarily because palliative care patients are dealing with deteriorating conditions, often at unpredictable rates. Hope theory and adaptation to life threatening illness provide useful adjuncts to already established theoretical goal setting literature.