Shared learning database

Hertfordshire Community NHS Trust
Published date:
March 2014

Current research is suggestive of high levels of depression in patients facing the end of life, yet inconsistent measurers and the context from which the research is undertaken, undermine any reliability and therefore accurate understanding of the psychological affect of terminal illness. We therefore needed to consider how we investigated and measured our patient group for psychological distress and to modify our practice according to our findings.
/br> Research was conducted in several planned stages, and our actions investigated through the implementation of an audit cycle. We continuously incorporate findings into subsequent stages of the research. Through incorporation of standardised tools and methods for the assessment of depression in our patients, we were able to increase the ability to identify distress, to allocate patients according to their level of distress, to ensure that clinicians are working within their competencies and to improve the quality of patient care.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

Our aim was to overcome reservations within a specialist palliative care team to use a diagnostic tool in respect of depression. Coupled to this, we also wanted to be able to measure the level of distress and to allocate resources that best supported the patient's psychological requirements within the differing competency levels in the team.

We therefore investigate the psychological care received from a community specialist palliative care team for 20 patients who were referred and assessed in a given month. In doing this we were keen to measure and understand the rate of depression and the interventions patients received. We were also able to see what was and wasn't working in our current practice and to consider new ways of working.

Our findings were presented at a service meeting and in discussion, it was agreed that we should look for a validated tool within Palliative Care that would support the identification of distress and a pathway from which patients could be allocated psychological support according to the NICE recommendations for Improving supportive and palliative care for adults with cancer. Key NICE recommendations include:
- People affected by cancer should be offered a range of physical, emotional, spiritual and social support.
- People with advanced cancer should have access to a range of services to improve their quality of life.
- There should be a trained workforce to provide services
We piloted a validated tool and were able to re-measure patient's psychological requirements and allocate according to identified need. We went on to develop new clinical supervision procedures and to develop a referral pathway for patients identified high levels of distress.

This work is on-going as part of an audit cycle in which the tool continues to be piloted and adopted in different contexts within the NHS and in the voluntary sector. This enables a replication of what we have achieved for more patients and their families, outside of specialist palliative care, to be identified according to distress levels and appropriate levels of support identified.

Reasons for implementing your project

We are a specialist community palliative care service hosted within the Hertfordshire Community NHS Trust. We became concerned about our identification of patients with psychological dilemmas and wanted to understand what we were currently doing, how it was working in respect of identification and what we needed to go on to do in respect of our findings. We started by auditing 20 case notes investigating through different measurers the reported psychological symptoms given by patients and used tools to assess for depression from the narrative given. We found that 33% of referrals to the specialist palliative care team were for psychological support, that 55% of patients were reporting depressive symptoms and that only 25% of patients were referred for psychological interventions.

In response to these findings, we agreed to conduct in several planned stages, and our actions investigated through the implementation of an audit cycle, the use of a tool to identify distress levels. In observing the effect of our actions at each stage of the cycle, we grew a scaffolding of knowledge which informed our actions and led to the discovery of best practice.

We continue to incorporate findings into subsequent stages of the research, as our learning is ongoing. Our learning this far has shown that through incorporation of standardised tools and methods for the assessment of depression in our patients, we were able to increases staff knowledge, to provide appropriate support and to improve patient care.

How did you implement the project

To better understand what best practice looks like, we needed to bring theory and practice together and gather information which gives us a bench mark from which we can measure against and then develop an action research process through an audit cycle.

Action research has been described by its creator, Lewin (Adelman, 1993) as a spiral of steps, each of which is composed of a circle of planning, action and fact finding about the result of the action. Our research was conducted in several planned stages, and our actions investigated through the implementation of an audit cycle. In observing the effect of our actions at each stage of the cycle, we were growing a scaffolding of knowledge which allowed us to continuously incorporate findings into subsequent stages of the research.
The process we followed can be summarised as follows:
1) Audit looking at current practice within the service and literature review.
2) Review of findings and actions agreed for future investigation.
3) 2nd audit looking at the result of our actions
4) Review of findings and actions agreed for future investigation.
5) 3rd audit looking at the result of our actions
6) Review of findings and actions agreed for future investigation.
7) 4th audit looking at the result of our actions
8) Review of findings and actions agreed for future investigation.

In order to identify and incorporate the best methods for assessing distress in a community palliative care setting, a two part audit was initially conducted. An audit involves comparing current practices of an institution with those most empirically and professionally supported to ensure the presence of evidence-based practice (Healthcare Improvement Scotland, 2007). Audits are used frequently in health care as a method of clinical governance to improve current practices and ensure the highest level of care quality (Healthcare Improvement Scotland, 2007). With such low levels of standardisation available empirically, it was predicted that the clinical practices of the specialist palliative care team would mirror the inconsistencies present in the existing literature. Therefore, the hypothesis was that depression occurring within patients receiving palliative care in the community would be under diagnosed.

Key findings

1st Cycle:
The findings of the piloted audit cycle identified that though 55% of patients were displaying signs of possible depression, only 25% were referred on for further psychological support. Of the initial reason for referrals made to the team, 35% were with the intention of acquiring psychological support services. The hypothesis that patient's were being under referred for psychological support was confirmed, due in part to a lack of standardisation in assessment methods. In seeking to remedy the issue and move forward, assessment was standardised though the inclusion of the DT in the secondary audit cycle.

2nd Cycle:
The secondary audit cycle incorporated the use of the DT, with the goal of all staff completing one within two clinical sessions with a patient. Feedback and training was provided by the team's lead psychotherapist. Staff were advised to discuss all DT scoring a six or above with the psychotherapist. Of the 137 referrals received by the service, 23 DT were attempted to be completed, with 17% of patients having a DT score. Of those that were completed, thirteen scored between 0-5 on the scale, with the remaining 4 scoring between 6-10 on the DT. 6 or the 23 DT attempted were not completed in their entirety.

3rd Cycle
The tertiary audit cycle incorporated two specialist palliative care localities and the Heart Failure team. At that time, there were 182 total accepted referrals to the teams. 81 DT were attempted, with 76 being completed fully. In the distress range between 1-5, 29 patients were scored. On the upper end of the scale between 6 -10, 13 patients scored. The 5 DT not completed were due to limitations of the patients capacity. Overall, 44.5% of patient assessments resulted in a DT being completed. That is an increase of 27.5% from the initial 17% in the second cycle. Due to the incorporation of the DT, 11 patients were referred on for psychological intervention. Of those patients, one refused further support.

Key learning points

The findings of the 1st audit identified that clinicians did not hold accurate beliefs about their ability to identify psychological distress. This enabled conversations to emerge where the introduction of a tool was seen as something that needed to be explored.

The second audit found that there was still a reluctance to use a tool, and the team agreed to implement measurers that were mandatory. The next audit cycle showed that the team who had most used the tool had a higher level of completing a DT and this was amplified in the 4th audit. The implication of this suggests that staff reservations around the use of the tool were diminishing. It also indicates that their understanding of the use of such a tool to drive improvement as part of the process was gaining momentum. This finding was replicated in further audit cycles, emphasising that an action research methodology supports change through the involvement of clinicians as part of the learning process. It also supports the evidencing, through participation, of best practice.

Using this methodology, invited participation to find solutions to the dilemma and helped shape an even playing field, between the different professions represented in the multi-disciplinary team. In not having all the answers and implementing solution ownership, through exploration and application, the success of what was being achieved belonged to all in equal measure.

Contact details

Ana Draper
Consultant Systemic Psychotherapist
Hertfordshire Community NHS Trust

Secondary care
Is the example industry-sponsored in any way?