The Rainy Day Care project tested a simple, practical, structured (yet flexible) bundle approach to ‘identify, assess and plan’ care for people with progressive life-limiting illness who may be nearing the end of life. The overarching aim of this project was to increase capacity for healthcare professionals to identify patients who are at risk of dying in a timely manner, so care could be better planned, more proactive, and align with the patient’s and family’s wishes. This project did not aim to duplicate the care provided by Specialist Palliative Care Services. Rather, the aim was to introduce the concept of anticipatory care planning for patients and families using the Rainy Day metaphor and upskill staff in how to provide a palliative approach.
The Rainy Day Care Project
Summary
Aim
This project aimed to:
- Pilot a simple patient-centred intervention that harnessed a palliative approach (Rainy Day Care bundle) in clinical practice.
- Explore the effect of support, coaching and education of health care professionals (mainly nurses) via project nurses with specialist knowledge of palliative approaches/strategies.
- Understand patients’ and families’ experiences of receiving Rainy Day Care.
- Explore consumers’ acceptance of the Rainy Day Care language and timing and methods of introducing the concept.
Benefits
The greatest benefit of the project was the knowledge and data generated to inform future projects, research, health services innovation and education. We now know that the Rainy Day Care approach is wanted (by staff and consumers) and is feasible. Use of a metaphor, and the education and support provided by the project nurses improved confidence around communication and patient management regarding palliative and end-of-life care.
Background
Recognition of people who are likely to be nearing the end of their life can prompt clinicians to reassess goals of care, focus on holistic needs, share decision making and engage in advance care planning (ACP). The identification of people who are anticipated to have a shortened life expectancy, for the purposes of providing an appropriate coordinated response, is a priority identified in the Statewide Strategy for end-of-life-care 2015, the National Consensus Statement: Essential elements for safe and high-quality end-of-life care, and the National Safety and Quality Health Service Standards (2nd edition).
Internationally, the concept of identifying risk of deteriorating and dying, or ‘rainy day thinking’ has gained momentum as a means of improving the quality of palliative and end-of-life care for people with progressive life-limiting illness. The metaphor is to take an umbrella with you when you leave the house if there is a high change of rain. To date, limited work has been conducted to evaluate the provision of ‘rainy day care’ and the use of this metaphor to facilitate pro-active palliative care planning.
Solutions Implemented
Key aspects of the project included the following:
Rainy Day Care bundle development
Project nurses experienced in palliative care reviewed the literature and available resources to develop a bundle that facilitated identification, assessment and planning for people who were likely to be nearing the end of life. This included a screening tool, prompt sheet, patient education resources, and staff education resources.
Rainy Day branding
Branding and merchandise were developed to be used as a conversation starter including t-shirts, posters, patient brochures, badges, stickers, and cupcakes.
Pre and post-implementation survey
A pre and post-implementation survey of mainly nursing staff was conducted to assesses knowledge and confidence in communication and patient management of palliative and end-of-life care.
Education and support of health care professionals
A range of educational material was utilised or developed by the project nurses to support staff (medical and nursing) to identify, assess and plan for people who may be nearing the end of life. A range of nursing in-services were developed for nursing staff in response to the pre-implementation survey. One-on-one support was provided to medical and nursing staff by the project nurses.
Rainy Day Care piloted
The Rainy Day Care bundle was piloted across five clinical areas between January and June 2018. An implementation science framework was used and field notes were gathered by the project nurses throughout.
Consumer engagement workshop
A consumer engagement workshop was held to explore consumers’ acceptance of the Rainy Day Care language and timing and methods of introducing the concept.
Evaluation and Results
Rainy Day branding
Rainy Day Care branding and merchandise was embraced by staff in all clinical areas. In total, 136 t-shits were ordered and patient education material and boards were used by staff in each clinical area.
Education and support of health care professionals
During implementation, 96 inservices were planned, but only 56 were delivered due to time restrictions in the clinical areas. One-on-one support and education of staff from project nurses was valuable and welcomed by medical and nursing staff.
Pre and post-implementation survey
There was a significant improvement in overall scores for confidence in palliative and end-of-life care communication and management from pre to post-implementation of the Rainy Day Care project.
Rainy Day Care bundle piloted
Between January and June 2018, the Rainy Day Care bundle was piloted on a total of 67 patients. Despite ongoing support and education, many nurses and medical staff still felt under-confident to engage in discussions about the potential for deteriorating and dying with patients and families. The bundle had to be adapted specifically for people with haemtological cancers. Many people identified as being in the final six months of life deteriorated rapidly and were not appropriate for Rainy Day Care.
Consumer engagement workshop
Consumers were divided about the metaphor for Rainy Day Care (some like it, others don’t understand it), but they liked the use of metaphors to talk about the topic. They also felt Rainy Day Care should be introduced earlier and was relevant for everyone, not just those nearing the end of life.
Lessons Learnt
- Nursing and medical staff welcomed support and education around how to identify, assess and plan for people who may be nearing the end of life.
- The Rainy Day Care bundle must be tailored specifically for each clinical area and different disease types.
- Ongoing support and education is needed (by a dedicated role) to facilitate Rainy Day Care in busy clinical environments.
- Nursing and medical staff liked Rainy Day branding and merchandise as a conversation starter.
- Consumers felt a greater focus on Rainy Day Care was definitely needed and would improve care and quality of life for people who may be nearing the end of life.
- It is important to focus on the ‘hope for the best…. prepare for the rest’ message using a metaphor that is appropriate for the individual patient.
- Rainy Day Care should be introduced earlier in the illness trajectory.
- We focused predominantly on education and support of nursing staff due to finite resources however, future projects must include medical staff.
- An implementation science framework was a valuable approach to implementing and evaluating this project.
