The vague language of the current Intermountain Healthcare (IH) description of primary care results in insufficient elaboration of specific nursing responsibilities such as quality of patient life, caregiver support, and non-discriminant patient treatment. A comprehensive primary care policy has not been adopted in the IH facilities, leaving care teams to devise an individual approach to each terminal patient, which may be inefficient and result in subpar service. Across the country, many HCPs lack knowledge and skills in pain and symptom management, communication, and care coordination, while the public has only a vague understanding of the benefits of primary care and how to access it (Meier et al., 2017). Given a wide range of responsibilities in providing palliative care (PC) and lack of specific instructions, IH healthcare providers (HCPs) filling only primary orders such as medical prescriptions may coincidentally neglect some care aspects. Therefore, an instructive primary care policy is needed to facilitate successful administration and ensure equitable access to care services in the IH facilities.
Policy Change Advocacies
Several issues affect the development of detailed palliative care policies. The rise in the cases of negligence and lack of supporting infrastructure has largely been attributed to a lack of change advocates. In response to these challenges, IH developed a hospital-based electronic palliative care algorithm to improve the identification of patients benefitting from PC services and calculate PC penetration rates (Gruhler et al., 2018). The algorithm indicated that the need for receiving PC might be as high as 26.4% of the total IH inpatient population (Gruhler et al., 2018). It will be progressively more challenging for HCPs to devise individualized care plans for IH patients with as high and potentially increasing numbers. Therefore, an approach with great universal applicability is needed to meet this demand.
Palliative care also faces problems of lack of focus on all the important service requirements. Facilities must adopt policies that address all issues regarding restructuring service. Palmryd et al. (2021) revealed that nurses caring for intensive care unit patients did not prioritize integrity, arguing that more explicit guidelines are required to ameliorate the issue. This issue may be applicable for the IH facilities, given that extant IH guidance on PC does not clearly identify the expectations and responsibilities of each party. Consequently, developing productive communication resulting in comprehensive care is crucial to meeting the needs of the facility.
Moreover, having a universal, comprehensive PC is critical as it opens a leeway for bias. A striking finding by Martinsson et al. (2018) revealed that patients’ quality of end-of-life care might depend on the disease the patient suffers. Similarly, Spraker-Perlman et al. (2019) found that IH patients without known critical conditions (CC) benefit significantly from PC support prior to their death just as much as patients without CC. Therefore, a non-discriminant approach in palliative care is a significant attribute that nursing and caregivers must implement through policy change.
Lastly, the protection of every nurse is crucial to caregiving, hence requiring supportive staff and protective gear, and infrastructure. The COVID-19 pandemic demonstrated that the lack of resources and nursing burnout contribute to the increased lack of care in PC (Human Rights Watch, 2021). In its Annual Report (2020a), IH recognized that its caregivers focused on creating personal protective equipment (PPE) assembly lines, with their regular duties seeing a significant decrease in hours because of the pandemic. This situation mandates ensuring that nurses can meet the care requirements. Hence, the policy to improve patient care should involve reconsidering the carer support system, as nurses’ workload can interfere with the quality and quantity of services provided.
The Vision for Policy Change
A successful policy change requires detailed attention to palliative success contributing factors, strategic goals, and budget plans. Focusing on these PC needs helps nurses ensure effective responsibility distribution and accountability standards non-compliance. The change must provide an appropriate level of detail in each aspect and implement enforcement mechanisms to avoid regular duties suffering due to negligence. Moreover, the change should result in a well-balanced staff to ensure no nurse experiences burnout because of working long hours.
Barriers to Effective Policy Change
Identifying barriers to change early is crucial to understanding ways to implement the proposed policies. The most common change distractors include nurses’ diverse demographics, morbidity and mortality rates, conflicting policies, and cultural differences. The COVID-19 pandemic highlighted that curative care is currently at the core of provider-patient interaction over any PC aspect. According to Intermountain Healthcare (2020a), hundreds of IH staff members volunteered to help in New York hospitals during acute results of the virus. The pandemic may have subsided, but IH facilities staff must have understood their core duties, where they must focus. Therefore, policy changes can mainly affect nursing staff needing explicit guidance on responsibilities and expectations. Further, the inpatient population of the IH facilities will be experiencing the consequences of the changed PC routine, which may initially affect caregiving services.
In addition, mortality rates in IH can affect the morale of caregivers, hence the need to address PC issues. Gruhler et al. (2018) estimate that 90 million Americans live with severe, life-threatening illnesses, and the figure will double within 25 years. There is strong evidence of PC reducing acute unplanned hospitalizations and specialized PC services associated with improved short- and long-term care outcomes (Sleeman et al., 2021). Therefore, improving the policy approach to specialist palliative care would improve overall patient comfort, especially when at the end of their life.
The poorly recognized role of end-of-life care in current policy contributes to unequal access to care. Although PC is increasingly recognized as a human right, the lack of guidelines’ support and research prevents many from utilizing it (Sleeman et al., 2021). Specifically, there are two downsides resulting from IH policy reliance on the individual POCs in facilitation end-of-life and palliative care. First, individualized POCs mean no universal standard of conduct is established; coupled with a potentially limited level of patient understanding of the services they may require, this could result in underperformance. Second, Intermountain Healthcare’s (2022) policy states that the hospice program and the patient’s physician must approve any proposed POC tests, procedures, and services, adding that “generally, treatments necessary for symptom or pain management” are approved. Therefore, the services beyond the necessary symptom management may not be approved.
The proposed change in policy would provide an all-encompassing transformation of the extant system. If many of the PC aspects in IH are currently dependent on creating individualized POCs, these aspects will be thoroughly regulated in the future system. For the IH care teams that are used to working closely with each patient, such a system may initially seem overly prescriptive. Additionally, the cultural background may influence patients’ decision-making regarding pain and PC, making it vital to consider the patient’s beliefs regarding care and death before forming an all-encompassing instructive guidance of staff conduct.
Appreciating Short-term Wins from the Policy Change
The success of any policy starts with the stakeholders of a given facility, and the influence spreads to all the parties involved in the nursing fraternity, including patients. America has seen tremendous growth in palliative care in the 21st century, indicating the national readiness for policy change and implementation. The IH facilities are receptive to innovative missions and have supported designing other healthcare policies, such as Primary Promise – IH’s plan to build children’s national model health system (Intermountain Healthcare, 2020a). Providers and policymakers have begun recognizing the potential benefits of PC for patients with severe illness at any stage (May et al., 2021). The major stakeholders are HCPs and terminally ill patients in IH facilities, both groups being receptive to potential policy changes.
Improving the Policy
The success of policy change relies heavily on the time and money invested in ensuring every proposition of the guidelines is achieved. Policy implementation outcomes are visibly reduced costs and quality care. According to Sleeman et al. (2021) and May et al. (2021), evidence supports the efficacy and cost-effectiveness of specialized PC. Sleeman et al. (2021) further reiterate that patients who receive early specialized PC show improvements in a range of outcomes, including physical symptom control, survival, and quality of life, and caregivers report increased satisfaction and decreased depression. Moreover, appropriate and timely provision of PC likely lowers the overall healthcare expenses (May et al., 2021). Therefore, the costs of keeping current HCPs and effectively helping patients in IH facilities may be reduced by implementing a new policy. The purpose of end-of-life care is for comfort, and not providing PC to them can increase their discomfort when in fact, we should be keeping them as comfortable as possible in their last hours or days.
Full Policy Change Adoption
Adopting new approaches to care practices may first prove challenging due to the barriers to policy change. On the contrary, the success of any policy change starts with the internal leaders and employees, and then the clients adopt these changes. According to May et al. (2021), various stakeholders have begun recognizing the potential benefits of PC for patients with severe illness at any stage. This reveals the need for continued efforts to ensure nurses understand and adopt these policies as part of the organizational culture and inculcate them to the patients. This top-down approach to policy change adoption can help IH develop its culture aligning with the facility’s principles and commitment to caregiving.
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