An evaluation of implementing integrated palliative care at an academic teaching hospital

Krause, Stephanie

An evaluation of implementing integrated palliative care at an academic teaching hospital

Thesis / Dissertation

2025

Publisher

University of Cape Town

Department

Department of Health and Rehabilitation Sciences

Faculty

Faculty of Health Sciences

Abstract

Palliative Care is presently being integrated within an academic teaching hospital in South Africa. The World Health Organisation has stated that palliative care is an ethical responsibility of health systems. However, despite a National Policy Framework and Strategy for Palliative Care, there is a limited funding allocation for Palliative Care in South Africa. South Africa experiences distinctive disease-related and contextual challenges that influence the normalisation of palliative care practice. Consequently, specific palliative care implementation strategies have been devised in response to the constraints of limited resources to suit this context. This research aims to evaluate and describe the effectiveness of the current integration strategies for Palliative Care within the South African Academic Teaching Hospital context, specifically Groote Schuur Hospital. The author conducted a descriptive and explorative study to describe and evaluate how and why these strategies contributed to integrating palliative care within the academic teaching hospital. The author drew from Valentijn's theory on integration to conceptualise the domains and extent of palliative care integration. Valentijn’s theory emphasises the interlink between the normative and functional aspects of integration and, furthermore, the extent of integration, which can be at a clinical, professional, organisational or systems level. The interlinking of these aspects is imperative in palliative care integration. Palliative care is also a complex intervention; therefore, understanding the context in which this complex intervention is being integrated is core to understanding how and why these interventions work. The author provides an in-depth description of the context to explain why palliative care integration worked or not. The author is an embedded researcher and was involved in developing and evaluating the strategies. The concerns of bias and trustworthiness of this research were ensured by using triangulation of data, member checking and including co-strategists from the implementation of these strategies in the evaluations. In chapter 1, the author provides background information, the substantive relevance and an overview of the research. Chapter 2 is a narrative literature review that provides an overview of implementation research, integration research and PC research convergence to beTer understand PC integration and implementation. The following chapters use interdisciplinary mixed-method evaluations conducted in three parallel phases. In chapter 3 the author describes the hospital's specific context in relation to the integration of palliative care. Chapter 3 is a mixed-method study to explore contextual factors influencing the integration or lack thereof in an academic teaching hospital. This approach assisted in expanding on the contextual phenomena, corroborating findings and explaining the interconnectedness between the different levels. Chapter 4 describes a sub-study to evaluate a structural change (introducing a specialised palliative care team). It is a mixed methods sequential study that evaluates and describes how the service is integrated into GSH. Chapter 5. A mixed method parallel study describes the evaluation of an educational approach (training oncology trainees). Chapter 6, a qualitative study, describes the evaluation of the effect of integrating PC into oncology training on PC integration. Chapter 7 describes the evaluation of a change in hospital processes (quality improvement in the care of patients with pancreatic adenocarcinoma). Chapter 7 is a mixed method sequential design and demonstrates how a quality improvement cycle contributed to palliative care integration. In Chapter 8, the strategies were analysed to assess their effectiveness in relation to integration and to identify the mechanisms that facilitate integration. The chapter draws conclusions from the research and makes recommendations on how to proceed with the integration of PC identifying areas for further research. The research methodology included primary interviews (n=20), focus group discussions (n=3), secondary data analysis, training evaluations, analysis of hospital data, Palliative Care service data, and targeted document analyses to expand and corroborate findings. The qualitative data were analysed using thematic analyses (inductive and deductive) using NVIVO. Quantitative data provided descriptive statistical analyses. This research has demonstrated that a specialised Palliative Care team successfully achieved clinical integration and normalised the practice of palliative care. Over a five-year period (2017-2022), a notable increase in referrals for Palliative Care services was observed. In 2017, the hospital received 737 palliative care referrals, which grew to 931 in 2020 and further escalated to 1202 in 2022, demonstrating a statistically significant upward trajectory. This increased reach extended initially from only medical wards but now includes include Outpatient services and Intensive Care Unit (ICU) care. The reason for the extent of the strategy is linked to the mechanism of observing palliative care being practised, which challenged the context-specific assumptions about Palliative Care. Furthermore, professional and clinical integration were achieved when the specialised service strategically collaborated in an area with a high burden of patients, like the surgical care of pancreatic adenocarcinoma, using an interactive quality improvement strategy. This resulted in a significant increase in comprehensive care and palliative care referrals. However, an educational strategy targeting junior trainees in oncology did not yield the expected clinical or professional integration outcomes. In oncology services documentation related to Palliative Care and perceptions among decision-makers remained largely unchanged. Notably, while full organisational integration was not achieved, the presence of the specialised Palliative Care team had a substantial impact on the hospital's organisational culture, creating a ripple effect throughout the institution because it normalised palliative care within the academic teaching hospital. This research underscores the vital role of specialised Palliative Care teams in enhancing clinical integration and shaping the broader healthcare environment, prompting further exploration and strategic adjustments for future improvement. This study confirms findings from other global studies that specialised Palliative Care teams play a central role in integration within a hospital sebng and shaping the broader healthcare environment, prompting further exploration and strategic adjustments for future improvement. Even with limited resources, specialised teams contribute to the process of integrating Palliative Care due to their capacity to transform a hospital's culture in relation to palliative care. Although educational strategies are important, the focus of these strategies should be on influencing both junior and senior staff and developing a palliative care team within hospitals.

Keywords

Academic teaching hospitals

Reference:

Collections

PhD / Doctoral

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