Commentary on Hewison A, Badger F, Clifford C &amp; Thomas K (2009) Delivering ‘Gold Standards’ in end‐of‐life care in care homes: a question of teamwork? <i>Journal of Clinical Nursing</i> 18, 1757–1766

The demographic profile of Western industrialised societies in the 21st century reflects an increasing ageing population. For example, it is projected that by 2026, 20% of the population of Canada will be over 65; already currently 75% of Canadian deaths occur in ‘seniors’ (Carstairs 2005, Katz 2008). Similarly in the UK, there are almost as many people over 65 as there are under 16 years of age (Office of National Statistics 2004, population statistics census). Thus dying in old age is now the norm in developed Western societies (Katz 2008). To respond to these huge demographic demands, changes in policy and practice globally have shifted the emphasis from providing good-quality palliative care to those people with cancer and who meet the criteria for care, onto the needs of previously ‘disadvantaged’ dying people, of whom older people comprise the largest group. There is currently much discussion around the palliative care needs of older people (Gott 2008), and this is placing care homes in the spotlight as a significant place of care and death at the end of life. Only in recent years has research in the USA, Canada, Australia and the UK specifically investigated the quality of dying and management of death in care-home settings (e.g. Katz et al. 1999, 2000a,b, Froggatt 2000, 2001a,b, Katz & Peace 2003, Seymour et al. 2005, Froggatt & Payne 2006). Studies and reports in the UK and in other countries have consistently observed the poor quality of dying in care settings and more recently have identified the urgency of improving terminal care in these settings and set targets for doing so [Palliative Care Australia (http://www.pallcare.org.au; accessed on November 2008), Owen & NCHRDF 2006]. In the UK, several palliative care programmes deemed successful in other settings have been trialled in care homes. These include: variants of the Liverpool Care Pathway, The Preferred Priorities for Care Plan and the Gold Standard Framework (GSF) in Care Homes. One such study is reported in the paper by Hewison et al. (2009), which is timely and noteworthy as it is one in the small but growing number of studies examining national and local initiatives within the care-home setting. This study by Hewison et al. (2009) reported findings on a study that investigated the introduction of the GSF for improving end-of-life care into care home in England. The GSF was devised eight years ago for primary care and is a locally based system that aims to optimise the organisation and quality of care for patients and carers in the last year of life (Thomas 2003). It is a framework of tools, tasks and resources and, as such, it requires that the multidisciplinary teamwork together and agree to its local implementation. It has more recently developed for the care-home context. A central feature of the study by Hewison et al. (2009) is that of teamwork and its importance in the successful implementation of new programmes of care. The authors urge that organisations wishing to implement such programmes should address the quality of teamwork before introducing them into practice. This seems to make sense in theory but, in practice, it might be more complex than it first appears as defining ‘teamwork’ is not straightforward. The meaning of ‘team’ and ‘teamwork’ is controversial (Payne 2000), and there is little empirical evidence of what is effective teamwork (Opie 2000, Cox & James 2008). A team is often defined as a group of people with diverse but related skills and knowledge who associate for the purpose of directing, co-ordinating and developing the separate parts as well as the sum total of their expertise (Pritchard & Pritchard 1994). In healthcare contexts, teamworking is often portrayed as a way to tackle the potential fragmentation of care, a means to widen skills and an essential part of the complexity of modern care (Firth-Cozens 1998). However, while the terms themselves may conjure up images of positive working relationships and a shared common goal, there is more to building an effective team than simply putting together a group of people (Zollo 1999, Cox & James 2008). Understanding teamwork and how it operates in healthcare delivery is complex. Healthcare teams have to contend with what Payne (2000) identified as three paradoxes common to all types of teamwork (Cox & James 2008). First, in the building of team relationships, they may become more inward looking and yet, in care services, it is often also essential to build relationships with professionals in other agencies and teams. This is a common feature of staff in care homes that are frequently low paid and sometimes isolated from what is often seen as ‘mainstream’ health care in order to provide a comprehensive service for patients. Second, members of a team often value it for the mutual support it offers in the face of the institutional demands placed upon them, yet sometimes managers see teamwork as an instrument for carrying out the organisation’s objectives. Also features of care-home workforce include recruitment difficulties, high turn over, limited training and part-time working. All these factors present challenges to achieving successful teamwork (Hewison et al. 2009). Here again this can be seen as an issue grappled with by many staff who work in care homes in a stressful situation with low staffing numbers and demanding work where death and loss is multiple and complex in nature for residents, staff and families. Finally, Payne (2000) suggested that teamwork requires us to think about interactions with colleagues and, yet in the current healthcare climate, teams and the services they deliver should be responsive to users’ needs. These three paradoxes mean that teamwork in healthcare settings is not straightforward as teams are often struggling with the tensions between their own needs and the needs of the organisations and consumers whom they are supposed to serve (Cox & James 2008). In addition, the empirical evidence supporting the notion of interdisciplinary teams is not always positive. A recent meta-analysis found that the palliative care team approach, after accounting for the composition of the team, patient diagnosis, country of study and study design resulted in benefits in the relief of pain and other symptoms. However, there were no significant effects for patient satisfaction therapeutic interventions (Higginson et al. 2003). As such, the assumption that interdisciplinary teams inevitably lead to greater patient satisfaction in non-palliative care settings can be challenged (Hermsen & ten Have 2005) and the need for evidence that such teams are indeed necessary is highlighted (Zwarenstein & Reeves 2000, O’Connor et al. 2006). In short, it is notoriously difficult to identify which particular elements of the team or its approach are most effective. Although Hewison et al. (2009) attempted to assess the extent of teamworking using a brief likert-style staff questionnaire, it is doubtful whether this type of approach could comprehensively capture the complexities of teamwork as discussed above. Although there is research to suggest (c.f. Grol & Grimshaw 2003) that protocols and guidelines, such as the GSF, are difficult to implement in practice, no such problems were uncovered within the study by Hewison et al., who found that professionals valued the GSF because of its positive effects on multidisciplinary working and communications. Process benefits were not generally discussed within this paper in relation to interactions with patients and the impact on patient or family care; moreover, the study findings focussed exclusively on the way professionals work with each other (Walshe et al. 2008). In this study, the findings were not linked to any patient outcomes of palliative care, such as clinical or cost-effectiveness but were reported in relation to the valued inter-professional processes of care such as knowing and communicating about patients regularly and effectively and improving relationships between professionals (Walshe et al. 2008). Hewison et al. (2009) selected only care homes that were participating in the GSF initiative as the study sample but does acknowledge that a limitation is that the ‘good’ staffing levels in the homes studied possibly set them apart from much of the sector that experiences staffing difficulties. The reliability of evaluative studies of the GSF, in common with other protocols, have been influenced by methodological problems such as non-random selection of settings (Thomas & Noble 2007) and purposeful sampling of settings and/or participants who have already been involved in GSF or so-called ‘champions’ for such initiatives (King et al. 2005, Walshe et al. 2008). In reality, few evaluations of these tools have been undertaken and do not look at the costs of development and implementation nor, importantly, the efficacy of care pathways in changing practice and improving outcomes. Although the best method of study would arguably be a randomised controlled trial of these protocols, this would not be feasible for ethical and methodological reasons (Ingleton et al. 2009). For example, whereas it may be possible to devise simple endpoints such as reduction in hospital admissions, care needs to be taken, as it cannot be assumed that all hospital admissions are inappropriate and a reduction in them is always a reflection of better clinical decision making. It is also difficult to define more complex outcomes for such interventions such as what constitutes a ‘good death’ (Stosz & Alaszewski 2008). The appropriateness of the end-of-life tools for care homes, albeit perceived as successful in other settings, has been questioned (Partington 2006). There has been a rapid expansion of the use of GSF probably because it is endorsed by national palliative care and supportive care guidance. The evidence base supporting the widespread adoption of GSF is, therefore, considerably less widespread and robust for such a well-supported initiative (Walshe et al. 2008), with little formal evaluation of their impact on professional practice, but moreover on patient outcomes. The wisdom of government organisations in endorsing them without proof of effectiveness has been raised (Owen & NCHRDF 2006). It could be that the successful implementation of any end-of-life tool, such as the GSF, depends on achieving the right balance between standardising practices and allowing professionals to use clinical judgement. In the context of palliative care, critics of protocols suggest that, left unchecked, there is a danger that the ‘process of dying’ may be reduced to a number of flow diagrams (algorithms as they were called in some palliative care journals) and a series of boxes ticked by professional carers instead of recognising the importance of spontaneity and creativity in palliative care (Kelly 2003). Importantly, the question still remains as to whether the introduction of such tools results in the benefits ascribed to them by their supporters and whether they warrant investment in time and resources to develop them. Hewison et al.’s (2009) paper reflected on one element of the evaluation of the implementation of GSF in care home. Further peer-reviewed publications arising from this evaluation are required to enable an informed debate about the efficacy of the GSF in care homes as an intervention that improves end-of-life care delivery in care homes.

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