Shared learning database

Hertfordshire Community NHS Trust
Published date:
October 2014

Specialist palliative and end of life care at Hertfordshire Community NHS Trust has implemented the use of the Distress Thermometer (DT) as an assessment tool to identify the psychological needs of patients who are palliative or end of life at Brunswick Court and there is an recognised need to support this practice for all patients who are identified as palliative or end of life.

We know that using traditional means of diagnosing for depression and anxiety with patients at the end of life is largely ineffective due to the possibility of determining a false positive, caused by confusion over the physical symptoms found in this area of care. The DT overcomes this predicament. In doing this we have increased our ability to accurately identify distress for this patient group in a residential setting and to provide appropriate treatment according to patient's distress level, thus improving quality of patient experience.

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:
1) To overcome barriers within a residential care home
2) To measure the level of distress of palliative and end of life patients and
3) To allocate resources that best supported the residents' psychological requirements within the differing competency levels of the care home and outside support agencies, such as a hospice and the NHS specialist palliative care team.

We mapped the current practice used within the care home to identify distress, and the referral process in place to support resident's emotional well-being. It was acknowledged that there was no consistent process in place and that identification was ad-hoc.

Our findings were discussed with the care home and their corporate body and 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 the use of a validated tool, on admission, to identify end of life patients and were able to re-measure resident's psychological requirements and allocate psychological support according to the identified need. We went on to develop clinical supervision procedures and established a referral pathway for residents identified with high levels of distress at the end of life. This work is part of an on-going audit cycle in which the tool and framework are being piloted and adopted in different contexts within the NHS and in the voluntary sector.

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 in care homes 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. It was proposed that a three months pilot takes place from which a conjoint way of working was trialled and ways forward were identified.

The pilot tried to achieve the following key components;
1. Distress Thermometer (DT) training and pilot introduction to identified staff.
2. DT's to be completed as a mandatory part of a new admission assessment process for palliative and end of life patients.
3. According to the scoring on the DT, a pathway for referrals is implemented.
4. Supervision for clinicians is provided by the allocated education facilitator for Brunswick Court.
5. All DT scorings and outcomes to be recorded by identified clinicians on an audit form It is recognised that there will be times when capacity or physical symptoms would make screening clinically inappropriate. When this is the case, it should be documented as a clinical judgement. Repeat DT's should be taken where possible after an intervention.
6. All DT's to be reported at the monthly Gold Standard Framework (GSF) meeting and referred for relevant psychological support as per the pathway.
7. An audit to take place post the pilot to determine what has been achieved

How did you implement the project

To better understand what best practice looks like in a residential care home, we needed to gather information which gives us a bench mark from which we can measure and then develop the actions required to quantity any change. This is an action process methodology which 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. Identification of staff:

Senior nurses were identified by the home manager to attend training in the assessment of patients' psychological health and wellbeing, as well as the use of the DT to measure the levels of distress being experienced. Training sessions took place with 10 members of staff and a confidence questionnaire was undertaken pre and post training.

The confidence questionnaire showed the following:
- Understanding why the DT tool has been designed? (5 = little confident), (4 = non confident at all)
- Recognising and assessing verbal and non-verbal signs of distress? (2 = quite confident) (7 = A little confident)
-Identifying services and resources that may help resolve a resident's distress? (1 = Quite confident) (8 = A little confident)
- Understanding your role within the distress thermometer pilot at Brunswick Court? (5 = A little confident, 3 not confident at all)

Resident information:
An information leaflet was devised for residents and their families about the screening tool and distributed within the care home as required. This was not monitored as part of the audit process.

The care home staff were supported by an educator, a clinical nurse specialist and had access to level 3 and 4 psychological support for identified residents.

Our investigation 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 building knowledge which allowed us to continuously incorporate findings into subsequent stages of the research.

Key findings

In the post education questionnaire staff reported the following:
- Understanding why the DT tool has been designed? (4 = very confident, 5 = quite confident, 1 = a little confident)
- Recognising and assessing verbal and no- verbal signs of distress? (9 = quite confident)
- Identifying services and resources that may help to resolve a resident's distress? (3 = Very confident, 6 = quite confident)
- Understanding your role within the distress thermometer pilot at Brunswick Court? (3 = very confident, 5 = quite confident, 1 = a little confident).

The use of the distress thermometer:
In the period of January 2014 until the July 2014 the 10 trained members of staff were requested to use the DT and a copy of the completed DT as well as a thematic log about its use was kept by the end of life educator.

In this period 14 DT's were completed by staff, of those DT's the following scoring was made:
<4 3 DT's
>4 + <7 10 DT's
>8 1

One DT's was unable to be completed fully due to identified capacity issues.

From a solution focus perspective 50 positives were selected in the following DT groupings. These were seen to give rise to the distress being experienced:
Physical: 38
Practical: 1
Emotional: 9
Family: 2
Spiritual/Religious: 0
Therefore 76% of issues that gave rise to distress were physical and 18% were emotional.

This also shows that the main rise for distress is attributed to physical concerns which with a solution focused approach and medical input could be resolved. Yet 6 of the DT's required a combined approach in that there was a mixture of physical and emotional distress. 3 prioritised the physical pain and 3 the emotional distress.

Also out of the 10 members of staff trained only 5 members of staff went on to actually complete the DT with residents. There were two DT's with no staff name, so there could be 7 members of staff who completed the DT, yet the reality of this is unknown.

Of the resident's screened, 9 of the 14 received level 2 psychological interventions and physical symptom management from the clinical nurse specialist, she was received clinical supervision for this work from the level 4 therapist.

The one resident who required a higher level of psychological support was referred to a level 3 practitioner who undertook assessment and delivered identified psychological interventions.

Key learning points

The following factors are crucial to the on-going success of such screening:
- Continued clinical support from a clinical nurse specialist in end of life and palliative care.
- On-going external educational stimuli and supervision that promotes the use of the tool.
- Amendment to the pathway that best reflects the findings of the audit and the action research process.
- Development of the GSF meeting to accommodate reflection and care planning for identified distressed patients.
- To engage the clinical manager in the role as champion to the screening of all residents who are identified at the end of life or palliative.
- To add the DT to patient notes as a trigger for its completion.
- That the internal clinical supervisor be supported through training in the use of the DT and required supervision.

There is also the need to consider embedding this way of working with additional training of identified staff to complete the DT, due to the rapid staff change over.

Contact details

Ana Draper
Consultant Systemic Psychotherapist
Hertfordshire Community NHS Trust

Is the example industry-sponsored in any way?