Summary

This research report comes at a crucial moment in the organization of end-of-life palliative care (Eol/PC) in Québec. With the aging of the population and the prevalence of chronic diseases, integration of a palliative care approach to health services is essential. At present, access to EoL/PC seamlessly integrated with all other healthcare services is rare. In Québec, end-of-life care is incorporated in curative care and there are few specialized palliative care units. This means that nurses and clinicians must provide curative care (often complex) together with end-of-life care (mixed approach) in a fast-paced work environment. In addition, in these work settings, where curative intent dominates, death is often perceived as a failure. The SATIN I project, on which this project is based, demonstrated that such environments generate stress and job dissatisfaction among nurses, who must carry out their duties while experiencing the intense emotions that accompany frequent and often painful deaths—particularly in high-tech sectors such as oncology and intensive care. Moral conflicts and ethical suffering were described in addition to other psychosocial risk factors (PSRF), such as lack of autonomy and heavy workloads, which affect satisfaction and well-being. With the adoption of the Act Respecting End-of-Life Care, EoL/PC is finally becoming a reality. The results of the SATIN II study highlight the need to consider not only the organization of Eol/PC but also the adaptive capabilities of those involved.

The SATIN II project consists of four workplace support programs designed to improve satisfaction and well-being at work and reduce PSRF among nurses and clinicians providing end-of-life care. The approach is based on the recommendations of the UK Medical Research Council (MRC-UK) for a two-phase development, implementation and evaluation intervention: the main goal of Phase I is development of an intervention to integrate a palliative care approach into current care practices in care units; Phase II involves evaluating the feasibility and impact of the intervention as well as pretesting the impact on certain indicators (satisfaction, well-being and PSRF).

Study 1 focuses on integrating a palliative care approach in two intensive care units (ICUs) in one particular hospital (site A and site B). End-of-life care and person-centred care were the selected care models. The implementation process was already under way at the time of finalizing this study. Most of the participants took the time to learn about the components of the intervention, and there was a positive attitude to the content and the implementation process, especially the participatory approach and the associated consultation process. The impact on clinical practice was evident in a greater awareness of values, development of shared meanings, a perception of humanization of care and openness to interprofessional collaboration—though this remained fragile and was observed more at one of the two sites. At this stage, there was not yet any association of the intervention with reduction or elimination of PSRF at work or with participant satisfaction or well-being. An improvement was however noted in PC competencies.

Study 2 focuses on integrating a palliative care approach soon after lung cancer diagnosis. Person-centred supportive care was selected as the care model. Two oncology outpatient clinics in the same hospital were chosen as study sites. Other sectors of care not dedicated solely to oncology but nonetheless along the care trajectory of the target clientele were invited to participate in certain program activities to promote integration of the approach throughout the care trajectory. The needs study conducted at the beginning of the project demonstrated that the clientele has unsatisfied information and emotional support needs. Clinicians and managers expressed a desire for support so they could better meet these needs. An intervention was developed in collaboration with stakeholders that called for coordinated use of patient-centred supportive care tools for lung cancer patients and their families/loved ones. A number of difficulties were encountered in the implementation stage, and it was thus not possible to really evaluate the impacts. The acceptability of the content, the suitability of the intervention as well as the challenges faced in its implementation were documented.

Study 3 is designed to integrate a palliative care approach to Eol/PC in an ICU in a particular hospital (not the same hospital as in Study 1). The selected care model is Eol/PC. The intervention includes online training and an integration activity. Despite an unfavourable context (budget cuts, abolition of a position, upcoming move) and despite the fact that it was more difficult and time-consuming to develop the intervention than expected (like other studies, given the wide-ranging reorganization of the health system), the intervention during the short implementation period had a positive quantitative as well as qualitative impact, (improvement in PC competencies and more rewarding experiences). The interdisciplinary integration activity and the flexibility of the online training were perceived as attractive and innovative solutions. The participatory approach was especially appreciated as were the educational materials designed to meet clinicians’ needs.

Study 4 benefitted from the contribution of one of Québec’s pioneering teams specializing in palliative care. The focus initially was on emotional support for carers. The objective of the intervention had to be revised, however, considering pressure stemming from organizational restructuring and relocation of the palliative care unit. An intervention focusing on team resilience (exploration of shared values) and emotional support for caregivers (mindfulness practice and meaningfulness) was developed. Despite the imminent move, qualitative assessment showed a number of positive impacts, backed by quantitative improvements in indicators (workload and rewards). The study offered an innovative solution that combined organizational and individual factors.

Integration. The quantitative results partially support the hypothesis that an intervention using a participatory process to integrate a palliative care approach can lead to greater satisfaction and well-being and reduce PSRF. The macro context and the many obstacles encountered lend credence to alternative hypotheses that partially explain null results observed. The qualitative results document positive effects on many indicators (satisfaction and PSRF). The assessment as a whole highlights the suitability of the participatory approach and active involvement of clinicians at all stages. The results suggest there is good reason to continue clinician-manager coconstruction efforts to provide quality Eol/PC services. Adopted in June 2014 by Québec’s national assembly, the Act respecting End-of-Life Care gives all Québecers the right to access to end-of-life care. By encouraging EoL/PC medical personnel and demonstrating with their help the feasibility of integrating a palliative care approach in a variety of ways in different sectors of care, the SATIN II project is a step in the right direction.