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The author reflects on the need to achieve the outcomes for professional health care chaplaincy as health care systems in industrialized countries such as Australia, Canada, and the U.S. are increasingly focused on outcomes. Topics discussed include focus on the unsustainable cost of health care, movement of chaplains in health care from being emissaries of local religious communities to integrated members of the health care team, and spiritual and religious needs in health care.

Abstract: Introduction: A pilot trial was carried out to determine if a focussed narrative interview could alleviate the components of suffering and anxiety and depression in advanced cancer patients. Intervention: Patients recruited were invited to participate in a focussed narrative interview and reflect on their perspectives on their sense of “meaning”, regarding suffering and their psychological, physical, social and spiritual well being – the emphasis was on allowing the patient to tell their story. Patients were encouraged to share what resources they themselves had utilised in addition to what professional care they may have received, to maintain a sense of well being. Method: Patients with advanced metastatic disease were recruited from hospices in the North West of England – the only exclusion criteria were not being able to understand written and spoken English and a non cancer diagnosis. At recruitment patients were asked to complete a numerical scale for suffering; the Brief Edinburgh Depression Scale, Edmonton Symptom Assessment Scale (ESAS), FACIT Spiritual well being questionnaire, Demographic information was collected and patients were randomised to either the intervention arm of the trial or the usual care arm of the study. Patients in both groups were invited to complete each measure at 2, 4 and 8 weeks. Results: One hundred people were recruited into the study – 49 were randomised to intervention group and 51 to control group. The median age of patients was 66 years age range (31–89 years) and 68% of patients were female. At baseline the ECOG performance of 75% of patients recruited was 1 or 2. The median survival of all patients in the study was 169.5 days (range 10 days to still alive at end of study). There was no significant difference at any timepoint in scores on suffering measure between intervention group and control group. At each time point the intervention demonstrated mean improvement in scores for depression and anxiety on ESAS – the greatest changes for both depression and anxiety were seen at 4 weeks. Conclusion: This pilot randomised controlled trial of a focussed narrative intervention demonstrated an improvement in mean changes in scores for depression and anxiety at 2, 4, and 8 weeks. We suggest this intervention may have beneficial effects on depression and anxiety, but a larger powered trial is required to determine the full effects. [Copyright &y& Elsevier]

Abstract: Context: Spirituality is a distinctive subject within palliative care practice and literature, but research to date is relatively undeveloped in this field and studies often throw more light on conceptual and methodological issues than producing reliable data for clinical practice. Objectives: To determine what is known about the spiritual needs of palliative care patients from the evidence presented in published research. Methods: Specialist online databases were interrogated for primary empirical studies of patients with a chronic disease unresponsive to curative treatment. Studies that only used a proxy for the patient or reported expert opinion were excluded. Each study was critically appraised for quality and the strength of its evidence to determine if any data could be pooled. Results: Thirty-five studies were identified, equating to a total of 1374 patients. Study populations were typically people with advanced-stage cancer, older than 60 years, who were English speaking, and with a Christian or Jewish religious affiliation, reflecting the predominance of Anglo-American studies. Studies fell into two groups: those that investigated the nature of spiritual experience and those that examined the relationship of spirituality with other phenomena. The evidence was insufficiently homogeneous to pool. Conclusion: Relevant accounts of what spirituality means for palliative care patients and evidence of how it operates in the lives of people with life-limiting disease can be derived from research. Studies to date are limited by reductive representations of spirituality and the conduct of research by health professionals within health care communities demarcated from disciplines and interpretive traditions of spirituality. [Copyright &y& Elsevier]

Conventional forms of healthcare are built on disciplinary thinking and practices that compartmentalize problems, treat delineated parts and dislocate the medical condition from the wider context of a person's life. In contrast, palliative care is founded upon a holistic philosophy that aims to understand and care for the whole person, and because this approach acknowledges that complex dynamic real-world problems cannot be addressed through a monocular view it works through the collaborative efforts of a multidisciplinary team. Transdisciplinary teams are strongly holistic through accommodating a breadth of perspectives, forging new interpretations and meanings, and developing coherent practices. In this study we discuss the value of transdisciplinary forms of palliative care and consider how this may apply to spiritual care. We consider spirituality as a complex, dynamic, and multidimensional field that can benefit from a transdisciplinary approach and outline the necessary conditions for spiritual care to be integrated into the practice of a transdisciplinary team. Finally, we consider the role of the chaplain in the team and the unique contribution of a chaplain's training and formation. We conclude that while transdisciplinary approaches to palliative care remain atypical it may be conceived as an expression of the most radical form of palliative care in all its dimensions. [ABSTRACT FROM AUTHOR]

Background: the need for access to high-quality palliative care at the end of life is becoming of increasing public health concern. The majority of deaths in the UK occur in acute hospitals, and older people are particularly likely to die in this setting. However, little is known about the barriers to palliative care provision for older people within acute hospitals.Objective: to explore the perspectives of health professionals regarding barriers to optimal palliative care for older people in acute hospitals.Methods: fifty-eight health professionals participated in eight focus groups and four semi-structured interviews.Results: participants identified various barriers to palliative care provision for older people, including attitudinal differences to the care of older people, a focus on curative treatments within hospitals and a lack of resources. Participants also reported differing understandings of whose responsibility it was to provide palliative care for older people, and uncertainly over the roles of specialist and generalist palliative care providers in acute hospitals.Conclusions: numerous barriers exist to the provision of high-quality palliative care for older people within acute hospital settings. Additional research is now required to further explore age-related issues contributing to poor access to palliative care. [ABSTRACT FROM PUBLISHER]

The Atchafalaya Bay system consists of a series of five shallow bays in southern Louisiana (U.S.A.) that are dominated by the circulation of the Atchafalaya River plume. Winter cold fronts have a significant impact on the resuspension and transport of sediments in this region, and a better understanding of the circulation during these events is absolutely necessary for determining the sediment transport patterns of the Atchafalaya Bay system and the adjacent shelf area. Understanding the circulation of this region is also crucial for environmental studies as well. This work describes the implementation of the Navy Coastal Ocean Model (NCOM), a three-dimensional numerical circulation model for tide, river, and wind-forced circulation in the Atchafalaya Bay system. The model has a cell size (Δx) of ∼800 m and is nested to a northern Gulf of Mexico model (Δx ∼ 5000 m), which is itself nested to the global NCOM (Δx ∼ 1/8°). Atmospheric forcing is supplied by the Navy Operational Global Atmospheric Prediction System (NOGAPS) (Δx = 1°). These models are used to simulate the hydrodynamics of the Atchafalaya Bay system and Atchafalaya river plume between December 1997 and January 1998 during the passage of three winter cold fronts. The water levels, salinity, and currents predicted by NCOM are in reasonable agreement with available measurements and tide-gauge elevation data. Errors in ebb tides and wind-driven circulation are attributable to uncertainties in the bathymetry and the low spatial and temporal resolution of the NOGAPS wind fields. [ABSTRACT FROM AUTHOR]

In Part 2 of our application of the Navy coastal ocean model (NCOM) to the Atchafalaya Bay system, we examine the wind- and tide-forced three-dimensional baroclinic circulation of the Lower Atchafalaya and Wax Lake Outlet river plumes. The salinity and the current velocity are examined during a time period when three cold fronts passed over the region. The baroclinic circulation of NCOM was validated for the same time period in Part 1 of this study (COBB, KEEN, and WALKER, 2008. Modeling the circulation of the Atchafalaya Bay region, 1: Model description and validation. Journal of Coastal Research, this issue). We find that the westward transport of plume water and the offshore cold-front- induced circulation are determined to a large extent by the alongshore and cross-shore bathymetric structure. Wind-driven plume water moves parallel to the alongshore bathymetric contours unless forced to mix with higher salinity water by strong cross-shore directed winds. The mixing of plume water with offshore water occurs over bathymetric shoals during periods of strong post-frontal winds. This mixing process involves the offshore transport of plume water over the entire water column in addition to the strong surface transport. The model results for offshore circulation are in qualitative agreement with past observations. In addition, the hydrodynamic processes that control the salinity fronts in Vermilion and West Cote Blanche Bays, areas where the model salinity was validated in Part 1, are examined as well. [ABSTRACT FROM AUTHOR]

This commentary continues a dialogue which began among literacy teacher educators attending an alternative format session about mentoring in the academy at a national conference. Literacy teacher educators participated in an informal discussion centered on the nature of mentoring in the academy for doctoral students, untenured professors, and tenured professors. Doctoral students focused on their changing identities and roles in the academy, their concerns about navigating the political infrastructure of academia, and the importance of assuming a proactive stance towards obtaining mentoring, especially for part‐time doctoral students. Untenured professors focused on the ways they were inventing and reinventing themselves within the power and politics of academia and their need for more holistic mentoring during these turbulent times. Tenured professors were able to embed mentoring experiences into their scholarly work and find ways to benefit or learn from mentoring experiences. These mentors also found comfort in more informal mentoring that included self‐initiated endeavors centered on mutual interests. Our commentary draws on these discussions as well as the professional literature on mentoring to describe the importance of mutual trust and reciprocity in mentoring throughout all stages of academia with attention to cultural and linguistic diversity. [ABSTRACT FROM AUTHOR]

Abstract: Although comparatively few people have regular contact with a church or spiritual leader, during times of terminal illness or bereavement, clergy are expected to be available and able to provide support. This study was carried out to determine the perceptions of clergy on the training they had received in supporting the dying patient and the bereaved. A sample of clergy working in the diocese of Sheffield was sent a questionnaire to assess what skills and knowledge clergy believed they had in this area, together with areas where they would wish for further training. The questionnaire was developed with input from hospital, hospice, and academic chaplains, and palliative care consultants. A subsidiary questionnaire was sent to clergy training colleges to evaluate the teaching offered. There was a trend across all denominations that those who had trained more recently were more likely to have received relevant training. Most clergy believed that they possessed adequate liturgical skills, but 13% felt they possessed none or little skill in pastoral care of the dying. Seventy-one percent indicated that they would like further training in pastoral care of the dying and 66.3% desired training in care of the bereaved. Of the 50% of training colleges that responded, the number of hours of training on pastoral care of the dying ranged from 6 to 36 hours (median 23 hours and mean 25 hours) and only 26% believed that their training in pastoral support skills was comprehensive. This study suggests that care of the dying and the bereaved is identified by clergy as an area in need of further training by the majority of clergy and should be part of the core curriculum within clergy training colleges and late training programs. [Copyright &y& Elsevier]

Spiritual care is an important aspect of holistic care. However, it is seldom the subject of audit, or included in quality standards. This article reports on the work of the Trent Hospice Audit Group (THAG) into the development of a quality standard for the assessment, delivery and evaluation of spiritual care. The standard was drafted by a multidisciplinary team and circulated among the THAG user group and other interested specialists, and subsequently revised. Three levels of assessment are defined and the different levels of expertise needed for these assessments identified. Education has been highlighted as a key issue in enable effective use of the standard package. Although acknowledging possible limitations and the importance of professional judgment, the standard should help provide a consistent approach to assessment, care planning and outcome review of spiritual care. [ABSTRACT FROM AUTHOR]

A review is presented of the book 'Spiritual Care at the End of Life: The Chaplain As a ‘Hopeful Presence,'' by Steve Nolan. [ABSTRACT FROM AUTHOR]

Aims and objectives To explore, using the example of a project working with older people in an outpatient setting in a large UK NHS Teaching hospital, how the constructs of Person Centred Nursing are reflected in interviews from participants in a Co-design led service improvement project. Background Person Centred Care and Person Centred Nursing are recognised terms in healthcare. Co-design (sometimes called participatory design) is an approach that seeks to involve all stakeholders in a creative process to deliver the best result, be this a product, technology or in this case a service. Co-design practice shares some of the underpinning philosophy of Person Centred Nursing and potentially has methods to aid in Person Centred Nursing implementation. Research design The research design was a qualitative secondary Directed analysis. Methods Seven interview transcripts from nurses and older people who had participated in a Co-design led improvement project in a large teaching hospital were transcribed and analysed. Two researchers analysed the transcripts for codes derived from McCormack & McCance's Person Centred Nursing Framework. Results The four most expressed codes were as follows: from the pre-requisites: knowing self; from care processes, engagement, working with patient's beliefs and values and shared Decision-making; and from Expected outcomes, involvement in care. This study describes the Co-design theory and practice that the participants responded to in the interviews and look at how the co-design activity facilitated elements of the Person Centred Nursing framework. Conclusions This study adds to the rich literature about using emancipatory and transformational approaches to Person Centred Nursing development, and is the first study exploring explicitly the potential contribution of Co-design to this area. Implications for practice Methods from Co-design allow older people to contribute as equals in a practice development project, co-design methods can facilitate nursing staff to engage meaningfully with older participants and develop a shared understanding and goals. The co-produced outputs of Co-design projects embody and value the expressed beliefs and values of staff and older people. [ABSTRACT FROM AUTHOR]

Spiritual care is an integral part of palliative care and if asked, most members of a palliative care team would state they address spiritual issues. The majority of hospices have support from a chaplain. This study was to determine the roles of chaplains within hospices and to look at their levels of stress. A questionnaire containing both open and closed questions was sent to chaplains working within hospices in the UK. The questionnaire enquired about number of sessions, specific roles of chaplain, whether they were members of the multidisciplinary team and their sources of internal support. Stress was measured on a 10-point Likert scale and the GHQ12. One hundred and fifteen questionnaires were returned, with a 72% response rate. The majority (62%) defined their denomination as Church of England and Free Church (24%); 71% of respondents had parish commitments in addition to their hospice role. Roles were predominantly defined as spiritual care of patients and staff (95%) and bereavement support of relatives (76%) and 75% regularly attended the multidisciplinary meetings. Senior medical and nursing staff and other chaplains were perceived as providing most support. Median Likert score for stressfulness was 5, and 23% scored at or above the threshold on the GHQ12 for identifiable psychological morbidity. Clear role definition was associated with less perceived stress whereas the provision of bereavement support was associated with statistically significant increased perceived stress. The role of a chaplain within a hospice is varied and this study suggests that the provision of training and formal support is to be recommended. [ABSTRACT FROM AUTHOR]

Missed appointments are an avoidable cost and resource inefficiency which impact upon the health of the patient and treatment outcomes. Health care services are increasingly utilizing reminder systems to manage these negative effects. This study explores the effectiveness of reminder systems for promoting attendance, cancellations, and rescheduling of appointments across all health care settings and for particular patient groups and the contextual factors which indicate that reminders are being employed sub-optimally. We used three inter-related reviews of quantitative and qualitative evidence. Firstly, using pre-existing models and theories, we developed a conceptual framework to inform our understanding of the contexts and mechanisms which influence reminder effectiveness. Secondly, we performed a review following Centre for Reviews and Dissemination guidelines to investigate the effectiveness of different methods of reminding patients to attend health service appointments. Finally, to supplement the effectiveness information, we completed a review informed by realist principles to identify factors likely to influence non-attendance behaviors and the effectiveness of reminders. We found consistent evidence that all types of reminder systems are effective at improving appointment attendance across a range of health care settings and patient populations. Reminder systems may also increase cancellation and rescheduling of unwanted appointments. "Reminder plus", which provides additional information beyond the reminder function may be more effective than simple reminders (ie, date, time, place) at reducing non-attendance at appointments in particular circumstances. We identified six areas of inefficiency which indicate that reminder systems are being used sub-optimally. Unless otherwise indicated, all patients should receive a reminder to facilitate attendance at their health care appointment. The choice of reminder system should be tailored to the individual service. To optimize appointment and reminder systems, health care services need supportive administrative processes to enhance attendance, cancellation, rescheduling, and re-allocation of appointments to other patients. [ABSTRACT FROM AUTHOR]

Improving co-design methods implies that we need to understand those methods, paying attention to not only the effect of method choices on design outcomes, but also how methods affect the people involved in co-design. In this article, we explore participants' experiences from a year-long participatory health service design project to develop ‘Better Outpatient Services for Older People’. The project followed a defined method called experience-based design (EBD), which represented the state of the art in participatory service design within the UK National Health Service. A sample of participants in the project took part in semi-structured interviews reflecting on their involvement in and their feelings about the project. Our findings suggest that the EBD method that we employed was successful in establishing positive working relationships among the different groups of stakeholders (staff, patients, carers, advocates and design researchers), although conflicts remained throughout the project. Participants' experiences highlighted issues of wider relevance in such participatory design: cost versus benefit, sense of project momentum, locus of control, and assumptions about how change takes place in a complex environment. We propose tactics for dealing with these issues that inform the future development of techniques in user-centred healthcare design. [ABSTRACT FROM AUTHOR]

The article discusses a survey of palliative care need undertaken in two Great Britain hospitals to explore the extent of palliative care need. It also explores the agreement between medical professionals, nursing professionals and Gold Standards Framework(GSF) in the identification of such patients. According to GSF, over a third of hospital in-patients meet the criteria to palliative care need but consensus in identification of patients was poor.

Background: There is clear evidence that the full range of services required to support people dying at home are far from being implemented, either in England or elsewhere. No studies to date have attempted to identify the proportion of hospital admissions that could have been avoided amongst patients with palliative care needs, given existing and current local services. This study aimed to examine the extent of potentially avoidable admissions amongst hospital patients with palliative care needs. Methods: A cross sectional survey of palliative care needs was undertaken in two acute hospitals in England. Appropriateness of admission was assessed by two Palliative Medicine Consultants using the following data collected from case notes: reasons for admission; diagnosis and co-morbidities; age and living arrangements; time and route of admission; medical and nursing plan on admission; specialist palliative care involvement; and evidence of cognitive impairment. Results: A total of 1359 inpatients were present in the two hospitals at the time of the census. Of the 654 consenting patients/consultees, complete case note data were collected for 580 patients; the analysis in this paper relates to these 580 patients. Amongst 208 patients meeting diagnostic and prognostic criteria for palliative care need in two acute settings in England, only 6.7% were identified as 'potentially avoidable' hospitalisations. These patients had a median age of 84. Half of the patients lived in residential or nursing homes and it was concluded that most could have received care in this setting in place of hospital. Conclusion: Our findings challenge assumptions that, within the existing configuration of palliative and end of life health and social care services, patients with palliative care needs experience a high level of potentially avoidable hospitalisations. [ABSTRACT FROM AUTHOR]

Background The need to more fully understand the economics of palliative care provision is widely acknowledged; however, the evidence base regarding the extent of potentially avoidable admissions in the last year of life, and the link between reducing/redistributing overall costs of end-of-life care has not been previously evaluated. Aim A narrative review of the evidence relating to the potential economic impact of reducing avoidable admissions among palliative care patients in the UK. Methods Ten electronic bases were searched in 2010 using key terms to identify UK literature relating to the economic consequence of avoidable hospital admissions among palliative care patients. Results Five studies met the inclusion criteria. Two were randomized controlled trials comparing the addition of new services to support patients in the community at the end of life with the existing standard service provided; one was a descriptive analysis of the change in usage and costs of health care services following the introduction of two community-based services; two were retrospective analyses of patient records for patient who had died in hospital to estimate the proportion of final admissions that could be classified as avoidable. Conclusions The evidence base from the UK relating to the economic impact of avoidable admissions in palliative care is limited. Although two recent retrospective studies suggest that there are currently high levels of avoidable admissions, the feasibility of avoiding such admissions and the full economic consequences of such changes have not been clearly demonstrated. Further evidence is needed to provide a more robust estimate of the extent to which the additional costs of providing high-quality community support are offset by reduced inpatient usage by palliative care patients. Prospective studies are needed which seek to demonstrate the scale of admissions which can actually be avoided in clinical practice, when issues such as capacity constraints come into play. [ABSTRACT FROM AUTHOR]

Although benign epithelioid peripheral nerve sheath tumors have been described, they are rare, and benign epithelioid schwannomas have not yet been established as a specific histologic variant. We present four cases of tumors which we believe would meet criteria to be classified as benign epithelioid schwannomas. Biopsy specimens obtained from four different patients were examined with routine and immunohistochemical staining. All the tumors were well-circumscribed lesions that were surrounded by a capsule containing EMA-positive cells. The cellular component was composed of epithelioid cells, in which there was a lack of mitotic activity. Immunohistochemical studies showed the tumor cells were S-100 protein and Leu 7 positive and HMB-45 negative. In addition, type IV collagen encircled individual cells within the tumor, indicating a continuous basal lamina. We report a group of cutaneous epithelioid schwannomas. Although the presence of such tumors is not unexpected, this diagnosis may not be initially considered because of this rare cytologic feature. [ABSTRACT FROM AUTHOR]